CurrentCareSourcePolicy AR-PAS-P-2417200b

ABA Prior Authorization Form

A provider-submitted prior authorization request form for Applied Behavioral Analysis (ABA) services for members (PASSE/Medicaid) including required provider/member information, request type, service units, billing CPT/HCPCS codes with unit definitions, submission methods, recommended documentation, and authorization time period guidance.

Policy Summary

PayerCareSource

PolicyABA Prior Authorization Form

Policy CodePolicy AR-PAS-P-2417200b

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must submit the completed ABA Prior Authorization Request Form via Provider Portal or fax (1-844-542-2608) with required provider and member information.

SourceLink

POLICY UPDATE CHANGES

No material changes

8ABA CPT codes on form

6 monthsMaximum authorization period

15 minBilling unit increment

Policy overview

This is a payer-specific prior authorization request form for Applied Behavioral Analysis (ABA) services for CareSource PASSE Medicaid members. The form captures required provider information (e.g., provider name, NPI, TIN, Medicaid ID, contact, address) and member information (e.g., member name, DOB, CareSource PASSE ID, Medicaid ID, care coordinator, ICD-10 diagnosis). It requires selection of the request type (Routine, Urgent, Retrospective) and requested service dates. The form lists the ABA CPT codes and their unit definitions (each 1 unit = 15 min) and fields for reporting total hours and total units per code. Submission methods are via the Provider Portal or fax (1-844-542-2608), and recommended supporting documentation includes screening/evaluation confirming autism diagnosis (e.g., ADOS, ADI-R), independent definitive diagnosis, ABA order, comprehensive assessment, IEP if applicable, individualized treatment plan with measurable SMART goals and hours/week, and for continued care, updated progress reports. Operational notes: a completed authorization request is required; an authorization may be issued for up to six months; and authorization is not a guarantee of payment — member eligibility must be verified at time of service.

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Form submission, authorization period, and applicability

Form Submission / Authorization Time Period / Limits

Instructions and limits for submitting an authorization request:

Submission and Authorization Requirements: Completed form is required for authorization submission

Submission via Provider Portal or Fax

Authorization Time Period: Up to six monthsUp to six months

A completed authorization is required and authorization is valid for up to six months

Payment Disclaimer and Eligibility: Authorization is not a guarantee of payment; member must be eligible at time of service

Authorization does not guarantee payment; verify member eligibility at time services are rendered

Prior Authorization

Submit completed prior authorization form

Submit the completed ABA Prior Authorization Request Form via the Provider Portal or fax. A completed form is required for authorization submission.

Prior Authorization

Authorization is required

Authorization is required. Authorizations are valid for up to six months. An authorization is not a guarantee of payment; member eligibility must be verified at the time services are rendered.

Required and recommended documentation

Documentation Recommended for Initial and Continued ABA Requests

Recommended documentation items (all recommended):

Screening and Behavioral Assessment: Screening/evaluation from a medical professional confirming an Autism diagnosis; behavioral assessments (e.g., ADOS, ADI-R)

Independent Behavior Assessment and Treatment Plan: Behavior assessment and treatment plan performed by an independent practitioner

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

ABA Order: ABA order from the requesting provider

Comprehensive Assessment Content: Assessment to include behavioral, psychological, developmental, and medical history

IEP When Applicable: Individualized Education Plan (IEP) when ABA hours will be performed in the school setting

Treatment Plan Details: Treatment plan to include measurable SMART goals, functional skills, assessments, caregiver/family training plan, and number of hours per week

Include number of hours per week and SMART goals

Continued Care Progress Documentation: For continued care requests: updated progress reports to show response to treatment

Documentation Required

Include recommended supporting documentation

Attach the following recommended supporting documentation with the request:

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

Billing Rule

Report units per 15-minute increment

Report services in 15-minute units. For each CPT code listed on the form, report the total units and/or total hours per week on the authorization form.

97151
97152
97153
97154
97155
97156
97157
97158

CPT codes and unit definitions used on form

ABA / CPT codes listed on formCPT

97151	Assessment and treatment planning by physician or BCBA (1 unit = 15 min) EP
97152	Behavior identification support by RBT or BCaBA/BCBA (1 unit = 15 min) EP
97153	Adaptive behavior treatment by protocol (direct 1:1) (1 unit = 15 min) EP
97154	Group adaptive behavior treatment (1 unit = 15 min) EP
97155	Adaptive behavior treatment with protocol modification/BCBA supervision (1 unit = 15 min) EP
97156	Family adaptive behavior treatment guidance (parent/family training) (1 unit = 15 min) EP
97157	Multiple-family group adaptive behavior treatment (1 unit = 15 min) EP
97158	Group adaptive behavior treatment with protocol modification (1 unit = 15 min) EP

Services are quantified in 15-minute units. Providers must report the total units and/or total hours per week for each CPT code on the form (fields provided for total hrs and total units for each listed code).

OpenPayer

ABA Prior Authorization Form

Policy overview

Form submission, authorization period, and applicability

Required and recommended documentation

CPT codes and unit definitions used on form

Definitions

Document revision history