Applied Behavior Analysis (ABA) Preauthorization Request Form
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This document is a preauthorization request form used by providers to request initial assessment, initial treatment, or continued ABA treatment for members with autism spectrum disorder and to submit required clinical documentation to Capital BlueCross.
No material clinical or coverage changes in this revision.
Coverage and Submission Criteria
Form submission and documentation criteria
Authorization requests must include ALL of the following documentation and meet stated submission rules
Per plan guidelines, authorizations cannot be backdated; the form will be used as the official request when hours differ from the treatment plan.
Per the plan guidelines, authorizations cannot be backdated. Requests must specify the requested authorization start date and supporting documentation submitted contemporaneously; initial assessment requests are limited to 60 days and initial or continued treatment authorizations are limited to 6 months.
CPT / HCPCS Codes and Frequency
Provider Submission Requirements and Risks
Prior Authorization Required
Providers must submit a completed ABA preauthorization request form selecting the CPT codes requested and specifying the number of hours/units per authorization period. Use the form’s requested authorization start date field — authorizations cannot be backdated. If hours on the form and hours in the treatment plan do not align, the form will be used as the official request. Fax the completed form and all applicable clinical documentation to 717.346.5819.
- Select appropriate CPT codes (see Treatment codes) and enter Hours per auth period and Units per auth period.
- Requested authorization start date must be within allowed windows: Initial assessment = up to 60 days; Initial treatment = up to 6 months; Continued treatment = up to 6 months.
- Authorizations cannot be backdated.
Clinical Justification Required for Select Codes
Some CPT codes require specific clinical justification and supporting data. When selecting these codes on the preauthorization form, include targeted documentation that supports medical necessity and the need for the requested hours/units.
Required Supporting Documentation
Include all applicable supporting documentation with the preauthorization request. Missing required documentation may result in delayed review or denial. Ensure documents are dated and identify the evaluator and servicing provider(s).
- Comprehensive diagnostic evaluation confirming DSM ASD diagnosis (include evaluator name and credentials).
- Results from a reliable, valid standardized assessment of functioning in ASD domains — repeated every 6–12 months as applicable.
- A plan of services dated no more than 30 days prior to the requested start date that includes: patient biopsychosocial information; clearly defined, measurable skill acquisition, behavior reduction, and caregiver goals across settings; quantifiable baseline, interim, and current data for all goals.
- Results of a functional behavioral assessment and description of function-based antecedent and consequence interventions; plans for skill maintenance and generalization; individualized criteria for fading and discharge.
- Description of any barriers to providing required information and efforts to resolve those barriers; any additional details to be considered for the request.
Administrative and Provider Information
Provide administrative and provider information on the form: patient demographics (name, DOB, patient ID), date of most recent diagnostic evaluation, evaluator name/credentials, servicing provider/agency name, TIN, NPI, service address, phone, requesting provider/supervisor name and contact information, ABA provider type, certification/state license and issuing state.
- Confirm whether a copy of the most recent diagnostic evaluation is attached.
- Include authorization-specific contact name, phone and fax for follow-up.
Submission and Documentation Risk
Authorizations cannot be backdated and missing or incomplete supporting documentation increases risk of denial or delay. Use the official preauthorization form and ensure consistency between requested hours on the form and in the treatment plan. Retain copies of fax confirmation when submitting.
- Do not submit requests with backdated start dates.
- Ensure all required supporting documents listed are attached; incomplete packets may be denied.
- Fax confirmation is recommended for proof of timely submission.
Clinical Background
Applied Behavior Analysis (ABA) is an evidence-based behavioral intervention provided for individuals with autism spectrum disorder to teach skill acquisition, reduce problem behaviors, and support caregivers. Authorization requests for ABA services use this preauthorization form and must include the requested start date and appropriate clinical documentation; the form supports requests for an initial assessment (up to 60 days) and for initial or continued treatment (up to 6 months).
Key Definitions
Applicable Level of Care
Outpatient
Outpatient ABA services — indicate requested modalities, locations, and units/hours as specified on the form.
Form includes fields for place of service and per‑day scheduling details.
ABA Clinical Documentation Requirements
ABA clinical documentation requirements
Required clinical elements to support authorization of ABA services
Some CPT codes listed on the form require additional specific clinical justification and supporting data.
Assessment, Treatment, and Caregiver Training
ABA (assessment, direct treatment, caregiver training)
Indicate which ABA modality CPT codes are being requested and enter hours/units for the authorization period.
Month option for frequency should only be chosen when the service occurs less than weekly.
Hours, Units, and Authorization Periods
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