Applied Behavior Analysis (ABA) — Prior Authorization and Coverage Criteria
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Governs prior authorization, provider qualifications, required documentation, and coverage parameters for ABA services under the Blue Cross of Idaho Federal Employee Program; applies to providers requesting ABA for enrolled members.
No material clinical or coverage changes in this revision.
Coverage criteria for ABA services
Medical necessity and coverage criteria for ABA
Covered when required documentation and provider qualifications support medical necessity:
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Note: ABA services provided within an educational facility are a contract exclusion and not covered. This exclusion is stated on the service request form and applies regardless of requested units or authorization status.
Requested and listed procedure codes
Provider submission, authorization, and documentation actions
Prior authorization required — submit form and records at least 10 days before elective service
Prior authorization is required for ABA services; submit the completed ABA request form and supporting medical records prior to services. Elective prior authorization requests should be submitted at least 10 days before the scheduled date of service. If approved, authorizations are issued for a 6-month period.
- Submit the completed form and medical records to the Behavioral Health fax listed on the form (Fax 208-387-6840).
- Approved ABA authorizations will cover up to a 6-month period.
No step therapy rules specified on the form
The request form does not specify any step therapy or prior-treatment sequencing rules for ABA services.
Required clinical documents — attach diagnostic initial evaluation and comprehensive treatment plan
Attach the Diagnostic Initial Evaluation and the Comprehensive Treatment Plan with your request; include all required components listed on the form.
- Diagnostic Initial Evaluation must include diagnostic tools (structured parent/caregiver interview and direct behavioral observation), evidence of communication/social deficits in ≥2 settings, repetitive/restrictive behaviors, intellectual functioning assessment (estimated IQ) and verification of no severe/profound intellectual disability.
- Comprehensive Treatment Plan must include behavioral targets with objective measurements; procedures for data collection/analysis; strategies for generalization; scheduled parent/caregiver training; and documentation of diagnoses with current ICD-10 codes from an MD.
Form and provider details — include BCBA name/contact and complete demographics
Complete all form fields for provider and demographics and include the BCBA provider name and contact number on the form to avoid processing delays.
- Provide BCBA (or licensed behavior analyst) name and contact number in the BCBA Provider and Contact Number field.
- Document supervisor qualifications and planned supervision frequency/ratio (form lists options such as at least 4 supervision sessions per month or at least 1 hour per 15 hours of direct treatment).
Submission and completeness risk — missing data may delay authorization; fax/phone is not authorization
Incomplete or missing information on the form may delay authorization; submission by fax or phone does not constitute authorization of services.
- Ensure all required clinical documents and demographic/provider fields are attached and completed to reduce delays.
- Do not assume authorization is granted upon fax or phone submission; Blue Cross of Idaho will notify you of the decision by secure email, mail, phone or fax.
Contract exclusion — ABA in educational facilities not covered
ABA services provided within an educational facility are a contract exclusion and are not covered under this policy.
Applied Behavior Analysis — documentation and supervision requirements
ABA documentation and supervision criteria
ABA-specific documentation and provider qualifications required for approval:
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Applied Behavior Analysis (ABA) treatment modalities
Applied Behavior Analysis (ABA) — top-level modality node
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Visit/unit limits and authorization period
Supervisor and provider qualifications
Background and scope notes
This authorization form is focused on Applied Behavior Analysis (ABA) for autism spectrum disorder (ASD) and requires documentation that confirms the ASD diagnosis and evaluates intellectual functioning. Required materials include a diagnostic initial evaluation with structured parent/caregiver interview and direct behavioral observation demonstrating communication/social deficits in two or more settings and presence of repetitive/restrictive behaviors, as well as an assessment of intellectual functioning including an estimated IQ and verification that there is no severe or profound intellectual disability.
The comprehensive treatment plan must address core ASD-related domains and problem behaviors with objective behavioral targets, data collection procedures, strategies for generalization, and scheduled parent/caregiver training. The request form also lists the ABA service codes to specify units requested (0362T, 0373T, 97151–97159) and indicates that approved authorizations, if granted, will cover up to a 6‑month period.
Case supervision must be provided by appropriately credentialed personnel (for example, a state‑licensed behavior analyst or a Board Certified Behavior Analyst BCBA/BCBA‑D) with documented supervision frequency or ratio; example options provided on the form include at least 4 supervision sessions per month or a ratio such as 1 hour per 15 hours of direct treatment. Include the BCBA provider name and contact number on the form to avoid processing delays.
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