CurrentCareSourcePolicy AR-PAS-P-2417200b

Applied Behavior Analysis (ABA) prior authorization for Autism Spectrum Disorder

This form and policy govern prior authorization requests and documentation requirements for ABA services for members with an autism diagnosis under CareSource PASSE in North Carolina; it outlines submission methods, timeframes, CPT/EP codes, and recommended supporting documentation.

Policy Summary

PayerCareSource

PolicyApplied Behavior Analysis (ABA) prior authorization for Autism Spectrum Disorder

Policy CodePolicy AR-PAS-P-2417200b

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit prior authorization via the Provider Portal or fax with required documentation including independent autism diagnosis, behavioral assessment, treatment plan with SMART goals, and ABA order.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Up to 6 moAuthorization time period

15 minUnit definition

1-844-542-2608Fax

ProviderPortal.CareSource.comProvider portal

Coverage Criteria

Authorization and documentation criteria

Covered when ALL of the following documentation and conditions are met:

ABA authorization prerequisites: Screening/evaluation from a medical professional with an autism diagnosis (e.g., ADOS, ADI-R)

[[4-6]]

Independent diagnosis: Definitive primary diagnosis of autism made by a practitioner independent of the ABA provider

[[4-6]]

Behavioral assessment and plan: Behavior assessment and treatment plan performed by an independent practitioner; treatment plan must include measurable SMART goals, functional skills, assessments, caregiver/family training plan, and number of hours per week

[[4-6]]

Policy Summary

PayerCareSource

PolicyApplied Behavior Analysis (ABA) prior authorization for Autism Spectrum Disorder

Policy CodePolicy AR-PAS-P-2417200b

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

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Covered when ALL of the following documentation and conditions are met: Screening/evaluation from a medical professional confirming an autism spectrum disorder diagnosis (examples: ADOS, ADI-R); a definitive primary autism diagnosis made by a practitioner independent of the ABA provider; a comprehensive behavior assessment and a behavior treatment plan performed by an independent practitioner; and a written ABA order from an authorized provider. The treatment plan must include measurable SMART goals, identified functional skills, required assessments, a caregiver/family training plan, and the number of hours per week proposed. Continued care or reauthorization requests must include updated progress reports demonstrating response to treatment.

Provider Actions and Submission

Prior Authorization

Prior Authorization Submission and Codes

Prior Authorization Required: Submit prior authorization requests using the Provider Portal or fax. Completed ABA Prior Authorization Request Form is required.

Provider Portal: ProviderPortal.CareSource.com
Fax: 1-844-542-2608
Authorization time period: up to six months
Unit definition: 1 unit = 15 minutes
Applicable CPT/Service line examples: 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158 (use EP modifiers as applicable)

Denial Risk

Eligibility and Payment Risk

Authorization is not a guarantee of payment. The member must be eligible and covered at the time services are rendered for claims to be paid.

Disclaimer: An authorization is not a guarantee of payment; member must be eligible at time services are rendered.

Documentation Required

Recommended Documentation for Authorization

Recommended documentation must accompany authorization requests to support medical necessity and continued care.

Screening/evaluation from a medical professional documenting an autism spectrum disorder diagnosis (e.g., ADOS, ADI-R)
Behavioral assessment and treatment plan performed by an independent practitioner
Definitive primary diagnosis of autism made by a practitioner independent of the ABA provider
ABA order from the ordering provider
Comprehensive assessment covering behavioral, psychological, developmental, and medical history
Individualized Education Plan (IEP) when ABA services will be provided in a school setting
Treatment plan with measurable SMART goals, functional skills targets, assessments, caregiver/family training plan, and number of hours per week
For continued care requests: updated progress reports demonstrating response to treatment

Background

Applied Behavior Analysis (ABA) is provided for members diagnosed with autism spectrum disorder and requires a multidisciplinary assessment and individualized treatment plan. The policy emphasizes independent diagnostic confirmation (screening/evaluation from a medical professional and instruments such as ADOS or ADI-R), a comprehensive behavioral assessment and treatment plan with measurable goals and caregiver training, and ongoing documentation of progress for continued authorization. Services listed on the prior authorization form include assessment, direct 1:1 therapy, group adaptive therapy, BCBA supervision, parent/family training, multi-family groups, and telehealth modalities; units are billed in increments where 1 unit = 15 minutes, and authorizations are issued for periods of up to six months.

Definitions

Unit

Unit definition (definitions section)1 unit = 15 min

Listed on formApplied to 97156 EP, 97157 EP, 97158 EP entries (total units calculated per 15-minute increments)

Use in reportingEnter total units on PA form as number of 15-minute units

CPT/EP codes (with EP modifiers)

Assessment (BCBA/Physician)97151 EP — Assessment/initial or reassessment (physician or BCBA)

Direct treatment by RBT/BCaBA97152 EP — RBT or BCaBA direct treatment

Direct therapy (1:1)97153 EP — Direct therapy (1:1)

Group adaptive therapy97154 EP — Group adaptive therapy

BCBA supervision / telehealth97155 EP — BCBA supervision; also listed for direct therapy (telehealth)

Parent/family training97156 EP — Parent / family training

Multi-family adaptive/multi-family group97157 EP / 97158 EP — Multi-family adaptive behavior and multi-family group

ABA Clinical Criteria

ABA clinical criteria

ABA-specific clinical and documentation expectations

Diagnostic confirmation: Screening/evaluation from a medical professional with an autism diagnosis (examples listed: ADOS, ADI-R)

[[4-6]]

Independent assessment and diagnosis: Behavioral assessment and treatment plan performed by an independent practitioner; definitive primary diagnosis of autism made by a practitioner independent of the ABA provider

[[4-6]]

Required treatment plan elements: Treatment plan must include measurable SMART goals, functional skills, relevant assessments, a caregiver/family training plan, and specified number of hours per week

[[4-6]]

Supporting documentation: ABA order from a provider and comprehensive assessment documentation including behavioral, psychological, developmental, and medical history; include IEP when applicable

[[4-6]]

Progress for continued care: Updated progress reports must be submitted for continued care requests to show response to treatment

[[4-6]]

OpenPayer

Applied Behavior Analysis (ABA) prior authorization for Autism Spectrum Disorder

Coverage Criteria

Coding and Units

Provider Actions and Submission

Background

Definitions

ABA Clinical Criteria

Treatment Modalities

Visit Limits and Related Codes

97151 EP	Assessment/initial or re-assessment (listed on form)
97152 EP	RBT or BCaBA direct treatment (listed on form)
97153 EP	Direct therapy (1:1)
97154 EP	Group adaptive therapy
97155 EP	BCBA supervision / direct therapy (telehealth)
97156 EP	Parent / family training
97157 EP	Multi-family adaptive behavior
97158 EP	Multi-family group