Blue Cross Blue Shield - Texas ABA Coverage Update

ABA coverage criteria and billing rules

Covered when ALL of the following conditions and billing rules are met:

ALL of the following

ABA services reimbursable only when provided by a Qualified Healthcare Professional (QHP) who is certified by the Behavior Analyst Certification Board (BACB) as a Behavior Analyst and/or licensed in their state as a Licensed Behavior Analyst or Licensed Psychologist.

ALL of the following

Services provided for educational, vocational, respite, or custodial purposes are not reimbursable.

ALL of the following

Services rendered in non-conventional settings (other than POS 10, 11, 12) require supporting rationale and a description of the unusual POS in the member record to be considered for reimbursement.

ALL of the following

Treatment plans and/or evaluations (inclusive of administration, scoring, interpretation, and report write-up) that exceed eight hours (32 units of CPT 97151) may not be eligible for reimbursement per industry standard coding guidelines.
CPT 97151 cannot be reported concurrently with other codes.

ALL of the following

When billing CPT 0362T or 0373T, services must be administered by the physician or QHP who is on-site; for a patient who exhibits destructive behavior; with the assistance of two or more technicians; and completed in an environment customized to the patient’s behavior (examples: separation from other patients, protective gear, padded rooms, medical monitoring).
These services should have defined treatment protocols separate and distinct from the patient’s other treatment protocols and may be better billed under other facility/procedural codes depending on setting and funding.

ALL of the following

Per CASP guidance, parent education is authorized up to 1 hour per week for a typical 26-week authorization period (total 26 hours). Requests for more than 1 hour per week require supporting clinical documentation.

ALL of the following

Indirect supervision activities are considered bundled (a practice expense) and are not eligible for separate reimbursement; documentation of supervision activities is expected in the treatment plan even when not reimbursed.
Direct supervision includes patient-present activities (direction of RBTs, fidelity monitoring, protocol modification) and may be authorized at a minimum of 1 hour per week when less than 10 hours of direct services are authorized.
Direct treatment codes (e.g., 97152, 97153, 97154) must be billed for work personally performed by the rendering provider or by appropriately trained technicians; services performed by caregivers are not eligible for reimbursement.

ALL of the following

CPT 97154 and 97158 are group codes and groups must contain 2–8 members.
QHP direction of technicians rendering 97154 is captured by 97155; QHP rendering group treatment with protocol modification is captured by 97158.

ALL of the following

Follow Medicare 15-minute unit guidance and the 8-minute rule when reporting multiple timed services; reported time must be the actual delivery time (exclude pre- and post-delivery activities).
If multiple 15-minute timed services are provided, apply the CMS MUE table guidance for maximum units per date of service and justify any units billed beyond industry standard coding guidelines.
If two or more different 15-minute services each are performed for 7 minutes or less but total ≥8 minutes, bill one unit for the service performed for the most minutes (same logic for three or more services).

ALL of the following

Records must include caregiver signature for each rendered service, the service/code provided, rendering provider name/signature, certification/credentials, place of service, date of service, beginning and end times of service, a written account/note of the service, and any required data points to substantiate services for audit.

ALL of the following

The rendering provider who delivers week-to-week treatment should bill for those services; providers should not bill for services they did not personally provide or through another provider’s NPI when unqualified.
Services performed by a supervisee and billed through a supervisor must follow applicable state laws, Board requirements, and CMS conventions for supervisor–supervisee documentation and billing.
Use a single modifier (HM, HN, HO) to indicate the level of education/training/certification of the rendering provider when billing CPT 97153.

ALL of the following

Co-treatment with other disciplines (e.g., Speech or Occupational Therapy) may be clinically indicated; co-treat sessions should be documented in the treatment plan and billed with appropriate modifiers.

ALL of the following

Refer to the most current CMS MUE table for guidance on maximum units per single date of service; service units are also limited by the specific authorization period and any units beyond industry standard must be justified in documentation.

ALL of the following

Indirect supervision activities are not separately reimbursable; services provided for educational, vocational, respite, or custodial purposes remain excluded from reimbursement.

ALL of the following

Plan medical policy (PSY301.021), applicable state mandates, and provider contracts govern reimbursement; providers must make documentation available upon request for audits or review.

CPT / HCPCS Codes and Units

ABA-related CPT/HCPCS codesmixed

0362T	Behavioral identification/support assessment, each 15 minutes
0373T	Adaptive behavior treatment, each 15 minutes
97151	Behavior identification assessment by physician/QHP
97152	Behavior identification support assessment by 1 technician
97153	Adaptive behavior treatment by technician
97154	Group adaptive behavior treatment by technician
97155	Adaptive behavior treatment by physician/QHP
97156	Family adaptive behavior treatment guidance by physician/QHP
97157	Multiple-family adaptive behavior treatment guidance
97158	Group adaptive behavior treatment by physician/QHP

Units per service — timed unit and billing rules

Unit lengthTimed CPT/HCPCS ABA services are billed in 15-minute units (Medicare 15-minute unit guidance).

8-minute ruleApply the 8-minute rule: a single 15-minute unit is justified for ≥8 and ≤22 minutes of treatment; when multiple timed services are provided, follow the Medicare 15-minute unit thresholds to calculate units.

CMS MUE guidanceProviders should refer to the current CMS MUE (Medically Unlikely Edit) table for maximum units per single member on a single date of service; service units are also limited by authorization periods.

Documentation of timeReport only actual patient treatment time (exclude pre/post delivery and non-treatment waiting/resting); record start and end times and note describing the specific modality in the medical record.

Concurrent reporting restrictionCPT code 97151 cannot be reported concurrently with other codes; treatment/evaluation time exceeding eight hours (32 units of 97151) may not be eligible for reimbursement.

Multiple short servicesIf two or more different 15-minute timed services are each ≤7 minutes but sum ≥8 minutes, bill one unit for the service with the longest minutes, applying the same logic for three or more services.

Provider Qualifications, Authorization & Documentation

Prior Authorization

QHP credentials and prior authorization alignment

ABA services are reimbursable only when provided by a Qualified Healthcare Professional (QHP) who is BACB-certified as a Behavior Analyst and/or state-licensed as a Behavior Analyst or Licensed Psychologist. Prior authorization and documentation must align with PSY301.021 and the member's benefit; units beyond industry-standard coding guidelines require justification and are subject to authorization limits.

Documentation Required

Plan documents and provider documentation submission

Plan documents and provider contracts govern in the event of conflict with this CPCP. Providers must submit accurate documentation of services performed and provide additional documentation upon request to substantiate claims.

Plan documents (e.g., Certificates, benefit booklets) or provider contracts control when conflicts exist.
Providers are responsible for submitting accurate claim documentation and must supply additional records upon request.

Billing Rule

Supervision billing and documentation requirements

Indirect supervision activities are considered bundled (a practice expense) and are not separately reimbursable; direct supervision may be authorized at a minimum of 1 hour per week when less than 10 hours of direct services are authorized. Session notes must reflect both parties present when direct personal supervision is claimed.

Indirect supervision (patient not present) — e.g., goal development, data analysis — is not separately reimbursable but should be documented in the treatment plan.
Direct supervision (patient present) includes direction of RBTs, fidelity monitoring, and protocol modification and may be authorized at ≥1 hour/week when <10 hours direct services are authorized.
Direct personal supervision requires the contracted provider to be in the immediate vicinity; session notes should reflect both parties present for the full encounter.

Key Definitions

Qualified Healthcare Professional (QHP)

DefinitionQualified Healthcare Professional (QHP) — a provider who is certified by the Behavior Analyst Certification Board (BACB) as a Behavior Analyst and/or licensed in their state as a Licensed Behavior Analyst or Licensed Psychologist.

Role — reimbursement prerequisiteABA services are reimbursable only when provided by a QHP; claims submitted for ABA services from non-QHPs are not reimbursable.

On-site requirement for high-intensity codesFor certain high-intensity codes (0362T/0373T), the physician or other qualified healthcare professional must be on site during the service.

Documentation expectationProvider records must demonstrate QHP credentials and licensure/certification as part of reimbursement documentation requirements.

Direct and Indirect Supervision — definitions and billing implications

Direct supervision — definitionPatient‑present activities including direction of Registered Behavior Technicians (RBTs), monitoring fidelity of implementation, and protocol modification; may be authorized at a minimum of 1 hour/week when <10 hours of direct services are authorized.

Indirect supervision — definitionPatient‑not‑present activities such as developing treatment goals, summarizing and analyzing data, coordinating care, progress reporting, transition/discharge planning, and training staff on new/revised protocols; these activities are bundled and not separately reimbursable.

Billing and reimbursement noteAMA codes treat indirect supervision activities as a practice expense (bundled) and they are not eligible for separate reimbursement, though documentation of supervision activities is expected in the treatment plan.

Time allocation guidanceCASP recommends ~20% of direct hours be spent in case supervision (direct + indirect) with ~50% of that supervision time for direct supervision; documentation of both types of supervision should be maintained.

OpenPayer

Applied Behavior Analysis

Coverage Criteria and Billing Rules

CPT / HCPCS Codes and Units

Provider Qualifications, Authorization & Documentation

Key Definitions