Autism Spectrum Disorders (Virginia Mandate)
Customize your policy alerts
Sign up for all CareFirst policy alerts
Know when CareFirst releases new policies or updates existing guidance.
Monitor payer policy activity
Defines CareFirst's operating procedure for habilitative services related to autism spectrum disorders for members covered under Virginia-issued plans, summarizing mandate history, benefit applicability, provider and documentation expectations. Affects providers delivering diagnosis and treatment (including ABA) to eligible Virginia members.
No material clinical or coverage changes in this revision.
Coverage Criteria and Scope
Covered Services / Provider Requirements
Covered when ALL of the following are met:
Check the member contract for exact applicability and effective dates.
Documentation of supervision must be maintained as required for reimbursement.
This policy defines CareFirst's operating procedure for habilitative services related to Autism Spectrum Disorder (ASD) for members covered under Virginia-issued plans. Coverage and applicability depend on the member's contract and the Virginia mandate revisions; specific contract provisions, restrictions, and exclusions take precedence and should be verified. The mandate history includes phased age applicability (originally ages 2–6, expanded to ages 2–10 for certain contracts, and extended to any age for individual and small group markets effective January 1, 2020), so providers must check the member's Virginia-issued policy to confirm whether the autism mandate applies to that contract.
There is no standalone policy-level medical necessity (NMN) statement in this Medical Policy Operating Procedure. Providers should follow the coverage criteria and operating procedure set forth elsewhere in this policy and rely on contract terms for determinations; the document explicitly notes that "There is no policy statement for this Medical Policy Operating Procedure."
Provider Responsibilities and Prior Authorization
Prior authorization verification
Some services, devices, drugs, and places of service may require prior authorization. Always check the member's contract for benefits. For Prior Authorization requirements please go to the Prior Authorization Look‑up tool (PAL Tool) at https://provider.carefirst.com/providers/medical/in-network-precertification-preauthorization.page or call 1-866-773-2884 (1-866-PRE-AUTH).
- PAL Tool: https://provider.carefirst.com/providers/medical/in-network-precertification-preauthorization.page
- Phone: 1-866-773-2884 (1-866-PRE-AUTH)
Prior authorization may be required
Prior authorization may be required for certain services, devices, drugs, and places of service. Failure to obtain required prior authorization may result in claim denial or member liability. Verify authorization requirements before providing services to reduce denial risk.
- Denial risk if authorization not obtained
- Check member contract and PAL Tool for scope of items requiring authorization
Required documentation on request
If requested by the Plan, a provider must make available supporting clinical documentation to substantiate medical necessity and the plan of care.
- Brief medical history
- Written evaluation establishing physical baseline data using objective tests/measurements when possible
- Plan of treatment including: diagnosis; short‑ and long‑term goals; type of procedures to be performed; frequency of visits per week; estimated duration of therapy; date of last certification by referring physician
- Treatment Plan reviews: Except for inpatient services, the Plan may request review of the Treatment Plan every 12 months or more frequently if the Plan and physician/psychologist agree
Provider action: ABA reporting and supervision
ABA services: only a licensed Behavior Analyst may report ABA services for reimbursement. Services provided by a licensed assistant behavior analyst must be supervised and documented by a licensed behavior analyst and reported by the licensed applied behavior analyst.
- ABA services reporting and supervision requirements
Clinical and Legislative Background
Per Virginia law and the Operating Procedure updates, Autism Spectrum Disorder (ASD) is defined consistent with the statutory definition and the Diagnostic and Statistical Manual of Mental Disorders. ASD is characterized by deficits in socialization and communication and by restrictive or repetitive interests and behaviors. For coverage purposes under Virginia mandates, diagnosis must be made by a licensed physician or licensed psychologist who determines the care to be medically necessary.
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.