Initial Diagnostic Eligibility
Covered for an initial diagnostic evaluation when ALL of the following requirements are met. Medical necessity review is required initially and every 6 months; the member's treatment record and supporting documentation must be submitted to CareSource before claim submission.
ALL of the following
The member has a definitive, primary diagnosis of autism spectrum disorder (ASD), including the ASD level, made after an evaluation independent of the ABA provider by a child and adolescent psychiatrist, clinical psychologist, child neurologist, or developmental pediatrician.
Standardized diagnostic assessment tools were used as part of the referral for services, such as the Autism Diagnostic Observation Schedule (ADOS), Autism Diagnostic Interview-Revised (ADI-R), or Childhood Autism Rating Scale, 2nd edition (CARS-2).
When the diagnostic evaluation was completed more than 24 months before the request, documentation describes clinical symptoms present within the past year that require treatment.
Symptoms must be specific to the member, related to the ASD diagnosis, and show a potential benefit from treatment; repeating DSM criteria or generic diagnostic language is insufficient.
Initial ABA Treatment Authorization
Initial ABA treatment authorization requires an individualized, current treatment plan and documentation demonstrating medical necessity, appropriate intensity, provider qualifications, and coordination of care.
ALL of the following
A licensed ABA practitioner performs a behavioral assessment (BA) and develops the treatment plan before services begin.
The BA generally may not exceed 8 hours every 6 months unless additional justification is provided and must be no older than 2 months when treatment authorization is requested. Additional assessment units will not be approved for assessments completed more than 2 months before the requested start date.
The plan includes
Biopsychosocial information, including current family structure; medication history with dosage and prescribing provider; medical history; school placement and hours per week, including homeschooling and applicable IEP or 504 information; history of ABA services and results; behavioral health diagnoses, services, and hospitalizations; other current or prior services such as speech, occupational, or physical therapy and coordination with those disciplines; caregiver proficiency and involvement; and major life changes.
Discontinuation and Titration
Titration and/or discontinuation should occur when ANY of the following conditions is present; this list is not all-inclusive.
ANY of the following
Treatment ceases to produce significant meaningful progress or the member has reached maximum benefit.
The member's behavior does not demonstrate meaningful progress for 2 successive 6-month authorization periods, as demonstrated by standardized assessments.
ABA therapy worsens symptoms, behaviors, or impairments.
Symptoms stabilize and allow transition to less intensive treatment or a lower level of care.
Parents or caregivers refuse treatment recommendations, are unable to participate in the treatment program, or fail to follow recommendations to an extent that compromises the efficacy of services or the member's progress.
The following services or activities are excluded or not reimbursable: services not documented in the treatment plan; services that are not medically necessary, are outside the scope of ABA, or are experimental, unproven, or investigational; education-related services or activities under IDEA; vocational services or services available under the Rehabilitation Act of 1973; components of adult day care programs; and services for members receiving other duplicative therapy services.
Treatment solely for the benefit of the family, caregiver, or therapist, or treatment of symptoms or behaviors that are not core symptoms of ASD, is excluded. Services are also excluded when they are more costly than an alternative service or sequence of services likely to produce equivalent diagnostic or therapeutic results, or when they duplicate therapy addressing the same behavioral goals as the treatment plan.
Education-related services under IDEA, vocational services under the Rehabilitation Act of 1973, and components of adult day care programs are not covered. Childcare, caregiver services, and services provided for the benefit of the family, caregiver, or therapist are also excluded.
Procedures or physical crisis-management techniques involving seclusion or manual, mechanical, or chemical restraint to control behavior are excluded.
Excluded services include individual supervision, personal care assistance, companionship, chaperoning, or shadowing regardless of activity or setting, including spas, camps, and wilderness programs. This exclusion applies whether services are reimbursed through another payer or provided by individuals without professional skills or training, including family members. Childcare and caregiver services, breaks for rest, lunch, or recess, and travel time are not reimbursable. Programs or services performed in nonconventional settings are excluded even when performed by a licensed provider. Services provided by an in-state healthcare provider while the member receiving ABA is out of state are also excluded.
More than one program manager or lead behavioral therapist, or more than one agency or organization providing ABA for a member at one time, is not covered. Services provided simultaneously by more than one ABA provider are excluded unless medically necessary, prior authorized, and indicated in the approved behavior plan.
Psychological testing, neuropsychology, psychotherapy, cognitive therapy, sex therapy, psychoanalysis, hypnotherapy, and long-term counseling are excluded from ABA coverage.
Concurrent or overlapping billing with speech therapy, occupational therapy, physical therapy, or other therapy services is not allowed. Services must be distinct in time, scope, and provider. For example, ABA from 10:00 a.m. to 11:30 a.m. overlapping speech therapy from 10:15 a.m. to 11:15 a.m. is not billable; ABA ending at 11:30 a.m. followed by speech therapy beginning at 11:45 a.m. may be billable when otherwise covered.
Reimbursement is not permitted for undocumented, out-of-scope, experimental, unproven, investigational, duplicative, or otherwise excluded services. Services that are unexpected to cause improvement, worsen symptoms, or prompt member regression are excluded. CareSource may monitor compliance through post-payment data analysis, medical review audits, recovery of overpayments, and provider prepayment review. CareSource may request documentation, particularly for telehealth or supervision; failure to submit records timely may result in recoupment.
Telehealth may be provided when medically necessary and supported by documentation describing service delivery, primarily adaptive behavior treatment with protocol modification or family adaptive behavior treatment guidance. Providers must use current best evidence and clinical consensus, consider member needs and resources, follow professional ethics, address licensure, regulatory, technology, and cultural limitations, and maintain protocols for appropriateness, risk assessment, safety planning, therapeutic benefit, competence, and peer-reviewed screening and suitability.
Treatment intended to address non-core ASD symptoms or behaviors, treatment that worsens symptoms or causes regression, and treatment not expected to produce improvement are excluded. Treatment must focus on remediation of ASD-related symptoms and functional impairments and be supported by individualized goals, measurable progress, and ongoing medical-necessity review.