Capital Bluecross ABA Prior Auth Coverage

Coverage Criteria for ABA Services

Initial and Continued ABA Treatment Authorization Criteria

Covered when the provider submits required documentation and completes the preauthorization form selecting the appropriate request type and listing CPT codes and units in 15-minute increments.

Authorization basic requirements: All of the following must be submitted: completed preauthorization form selecting Initial assessment (60 days) or Initial treatment (6 months) or Continued treatment (6 months); fax the completed form and all applicable clinical documentation to the specified fax number; specify CPT codes and number of units (15-minute increments) on the form; plan of services dated ≤30 days before requested start date containing biopsychosocial information, measurable skill acquisition and behavior reduction goals across settings, quantifiable baseline/interim/current data, functional behavioral assessment and function-based interventions, maintenance/generalization plans, individualized fading/discharge criteria, and description of barriers and efforts to resolve them.

If hours on the form do not align with hours in the treatment plan, this form will be used as the official request.

Assessment requirements: If requesting an assessment code, include comprehensive diagnostic evaluation confirming DSM diagnosis of autism spectrum disorder and results from a reliable, valid standardized assessment of functioning (standardized assessments repeated every 6–12 months).

Assessment CPTs listed on the form include 97151, 97152, and 0362T (0362T requires specific clinical justification and supporting data).

Initial and continued treatment prerequisites: For initial or continued treatment requests include a current plan of services (dated ≤30 days before start date) with measurable goals and baseline/interim/current data; for continued treatment submit updated plan of services and repeat standardized assessment results as applicable demonstrating interim data and progress toward goals and criteria for fading/discharge.

Authorization durations: Initial assessment = 60 days; Initial treatment = 6 months; Continued treatment = 6 months.

Authorizations cannot be backdated. Requests must use the requested authorization start date on the preauthorization form; incomplete dates or attempts to place an earlier effective date will not be accepted. Submit the completed form and supporting documentation by fax to the number shown on the form to avoid processing delays.

Common reasons requests are considered incomplete include missing a comprehensive diagnostic evaluation confirming a DSM diagnosis of ASD; absence of results from a reliable standardized assessment (or outdated results — these should be repeated every 6–12 months as applicable); lack of a plan of services dated within 30 days of the requested start date; plans that do not include measurable skill-acquisition and behavior-reduction goals with quantifiable baseline/interim/current data; missing functional behavioral assessment results and function-based interventions; or missing documentation of maintenance/generalization plans, individualized fading/discharge criteria, or descriptions of barriers and efforts to resolve them.

Coding and Billing

Assessment CPT CodesCPT

97151	Assessment code (listed on form)
97152	Assessment code (listed on form)
0362T	Assessment code (requires specific clinical justification and supporting data)

Treatment CPT CodesCPT

97153	Adaptive behavior treatment by protocol, administered by technician under the direction of a BCBA
97154	Group adaptive behavior treatment by protocol
97155	Adaptive behavior treatment with protocol modification, administered by a physician/other qualified health care professional
97156	Family adaptive behavior treatment guidance, administered by technician
97157	Multiple-family adaptive behavior treatment guidance
97158	Group adaptive behavior treatment guidance
0373T	Family adaptive behavior treatment guidance (requires specific clinical justification and supporting data)

Unit increment (inv-06)

Billing unit granularityUnits are billed in 15‑minute increments (four units = one hour).

Unit expression on formEnter number of hours requested and total number of units per authorization period; all units are 15‑minute increments.

Official request precedenceIf hours on this form and hours in the treatment plan do not align, this form will be used as the official request.

Provider Submission Requirements and Risks

Prior Authorization

Prior Authorization Required

Fax the completed Preauthorization Request Form for Initial Assessment and Treatment and all required clinical documentation to 717.346.5819. On the form, select the appropriate request type (Initial assessment — 60 days; Initial treatment — 6 months; Continued treatment — 6 months) and enter the requested authorization start date. Note: authorizations cannot be backdated — the requested start date must be on or after the submission date. If hours listed on this form do not match hours in the treatment plan, the form will be used as the official request; ensure consistency before submission.

Fax number: 717.346.5819
Request types: Initial assessment (60 days); Initial treatment (6 months); Continued treatment (6 months)
Requested authorization start date — cannot be backdated
Form hours override treatment plan hours — ensure alignment

Documentation Required

Required Supporting Documentation

Background

Applied Behavior Analysis (ABA) services are requested for patients with Autism Spectrum Disorder (ASD) and require a diagnostic evaluation confirming the DSM diagnosis plus standardized assessment results to document functional status and guide individualized treatment planning. Providers must complete and fax the preauthorization form selecting the appropriate request type — Initial assessment (60 days), Initial treatment (6 months), or Continued treatment (6 months) — and include the supporting clinical documentation and CPT codes/units as specified on the form.

Definitions

Plan of services requirements (inv-12)

Required datingPlan of services must be dated no more than 30 days prior to the requested start date.

Biopsychosocial informationInclude patient biopsychosocial information in the plan of services.

Measurable goals and dataClearly defined, measurable skill acquisition, behavior reduction, and caregiver goals with quantifiable baseline, interim, and current data for all goals.

Functional behavioral assessment (FBA)Include results of a functional behavioral assessment and a description of function‑based antecedent and consequence interventions.

Maintenance, generalization, dischargePlans for skill maintenance and generalization, individualized and realistic criteria for fading and discharge must be included.

BarriersDescribe any barriers to providing the required information and efforts taken to resolve those barriers.

Level of Care: Outpatient and Home-based ABA

Outpatient ABA / Home-based ABA

Level-of-care requests for outpatient/home-based ABA require selection of setting and submission of specified documentation and coding on the preauthorization form.

Admission (authorization) prerequisites: Submit the completed preauthorization form selecting the appropriate request type (Initial assessment 60 days; Initial treatment 6 months; Continued treatment 6 months), fax the form and all applicable supporting documentation to the specified number, and specify CPT codes and units (15‑minute increments) for the requested services.

Authorizations cannot be backdated.

Setting and frequency selection: Indicate outpatient ABA or home‑based ABA as the level of care and specify hours per week or per month for each selected CPT; choose month only when frequency is less than weekly.

All units are 15‑minute increments (four units = one hour).

Required supporting documentation for level of care: Include comprehensive diagnostic evaluation confirming DSM ASD, reliable standardized assessment results (repeated every 6–12 months), and a plan of services dated ≤30 days before start date with biopsychosocial information, measurable goals, baseline/interim/current data, functional behavioral assessment and function‑based interventions, maintenance/generalization plans, and individualized fading/discharge criteria.

ABA Documentation and CPT Selection Criteria

ABA documentation criteria

Documentation and code-selection rules specific to ABA assessment and treatment requests.

Documentation requirements for ABA: Provide a comprehensive DSM‑confirming diagnostic evaluation; results from a reliable standardized assessment of functioning (repeat every 6–12 months); and a plan of services dated no more than 30 days before the requested start date that includes biopsychosocial information, measurable skill acquisition and behavior reduction goals across settings, quantifiable baseline/interim/current data, functional behavioral assessment and function‑based antecedent/consequence interventions, plans for maintenance and generalization, individualized criteria for fading and discharge, and description of barriers and efforts to resolve them.

0362T and 0373T require specific clinical justification and supporting data.

CPT selection and units: Select the CPT codes that align with the services being requested and enter the number of hours and total number of units per authorization period on the form. Use assessment codes 97151, 97152, and 0362T for assessments; use treatment codes 97153, 97154, 97155, 97156, 97157, 97158, and 0373T for treatment. All units are 15‑minute increments (four units = one hour).

When frequency is less than weekly, month may be selected; codes marked with ** require specific justification.

Treatment Modalities

ABA (adaptive behavior treatment; family guidance)

Treatment modality selection: Select applicable CPT treatment codes and specify hours per week or per month and units per authorization period; if frequency is less than weekly, select the month option.

Units are 15‑minute increments.

Visit Limits and Unit Conversion

All listed CPT codes (inv-16)

Units expressed in 15‑minute incrementsAll listed CPT codes on the form use units expressed in 15‑minute increments (four units = one hour).

Assessment CPT codes includedAssessment codes listed on the form include 97151, 97152, and 0362T (0362T requires specific clinical justification).

Treatment CPT codes includedTreatment codes listed include 97153, 97154, 97155, 97156, 97157, 97158, and 0373T (0373T requires specific clinical justification).

Form instructions for codes and unitsSelect the CPT codes that align with requested services and enter hours requested and total units per authorization period on the form.

OpenPayer

Preauthorization for initial ABA assessment and treatment