Initiation and Continuation of Applied Behavior Analysis (ABA) Therapy Form
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This document is the payer's authorization form and instructions governing requests for initiation and continuation of ABA therapy for members; it applies to providers submitting prior authorization for ABA services to Blue Cross Blue Shield - Tennessee.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Initial and Continuation Authorization Criteria
Covered when ALL of the following administrative and clinical items are provided and support medical necessity:
Required for any authorization request
Used to evaluate necessity and intensity
Supports need for continued or increased services
Authorization length and renewal frequency must be observed
The form clarifies that the authorized ABA hours per week are not inclusive of other services the member may be receiving (for example, occupational therapy or physical therapy). When documenting a request, providers should list the ABA hours requested on the form and separately document any concurrent therapies so the reviewer can distinguish ABA intensity from other service modalities.
The form requires documentation of measurable goals and whether measurable progress has been made toward those goals. Lack of documented progress or failure to show how behaviors impair participation in age‑appropriate home, school, or community activities may jeopardize coverage determinations. Providers should include explicit progress notes and explain whether progress would be maintained if ABA were reduced or discontinued to support continuing medical necessity.
Additionally, continuation requests must be submitted at least once every six months (26 weeks), so up-to-date progress documentation covering the prior authorization period should be provided with each renewal to avoid delays or denials.
Coding and Certification Period
| No codes listed |
Provider Submission Requirements and Actions
Prior authorization required every 6 months
Prior authorization requests for initiation and continuation of ABA services must be submitted using the form; continuation requests are required at least once every six months and certification periods cover six months (26 weeks).
- Submit completed form as an attachment via Availity (TN providers) or provider portal/Cohere (out-of-state).
- Requests for continuation must be submitted at least once every six months (certification period = six months/26 weeks).
Assessment of prior service intensity
Document prior ABA service history including whether prior services occurred, the first ABA treatment start date, intensity classification (Focused or Comprehensive), average hours per week, and whether services have been continuous or had gaps.
- Indicate if member had ABA with another provider and provide the first ABA treatment start date.
- Select intensity: Focused or Comprehensive and record average number of hours/week.
- Explain any gaps in services and dates and list accomplishments from prior ABA services.
Required documentation
Include diagnostic confirmation, ABA treatment history, measurable existing and proposed goals with progress, parent/caregiver involvement, justification for requested hours, and provider signature/contact information on the form.
- Provide diagnostic confirmation (diagnostic reports, doctor's orders) and select ASD severity level (Level 1, 2, or 3).
- List measurable existing goals with progress and new proposed goals; document parent/caregiver involvement.
- Justify hours requested, describe functional impact on participation in age-appropriate activities, and include provider signature, printed name, credentials, and date.
Documentation and submission timing
Failure to submit continuation requests at least once every six months or omission of required clinical information (diagnostic confirmation, treatment goals/progress, justification for hours, or provider signature) may result in denial or delay of authorization.
- Continuation requests must be submitted at least once every six months; certification period fields (start/end date) must be completed.
- Ensure clinical information provided includes diagnosis confirmation, measurable goals with documented progress, justification for increases in hours, and provider signature to avoid denial or delay.
Behavioral Health ABA Documentation Criteria
Behavioral health ABA documentation criteria
Criteria the provider must document for ABA authorization and continuation:
Helps determine continuity and appropriate intensity
Required for continuation decisions
Supports medical necessity for continued or increased hours
Used to determine appropriate weekly intensity and coordination with other services
Required for processing
Service Definitions and Severity Levels
Visit Limits and Intensity
Background
Applied Behavior Analysis (ABA) is a therapy commonly provided for individuals diagnosed with Autism Spectrum Disorder (ASD). The form requests diagnostic confirmation, selection of ASD severity level (Level 1, 2, or 3), and detailed ABA treatment history to determine appropriate intensity.
To establish medical necessity and appropriate service intensity, providers should document existing and proposed measurable goals, parent/caregiver involvement, prior ABA start dates and intensity (e.g., Focused versus Comprehensive), and a description of functional impairment that interferes with participation in age‑appropriate activities.
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