CurrentCareSourcePolicy MM-1227

Applied Behavior Analysis for Autism Spectrum Disorder-AR PASSE- MM-1227

Defines medical necessity, documentation, provider qualifications, initial and continuing authorization, supervision, telehealth, exclusions, and recordkeeping requirements for ABA services for Arkansas PASSE members under CareSource.

Policy Summary

PayerCareSource

PolicyApplied Behavior Analysis for Autism Spectrum Disorder-AR PASSE- MM-1227

Policy CodePolicy MM-1227

Change TypeRevisedArchived

Effective DateJun 1, 2024

Next Review Date

Key ActionMedical necessity review is required for all ABA services initially and every 6 months; submit required documentation including diagnosis, standardized assessment tools, initial behavioral assessment by BCBA, and detailed treatment plan supporting requested hours.

SourceLink

POLICY UPDATE CHANGES

Policy revised on 01/04/2023 and 03/29/2023 with additions including definition of PCSP, PSSP, revised initial ABA treatment plan and parent/caregiver involvement; telehealth exclusions removed.

Policy archived with end date 2024-12-31.

Every 6 monthsAuthorization Interval

8 hoursBehavioral Assessment Limit (typical)

5%Minimum RBT Supervision Percentage

10 yearsClinical Record Retention

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7 yearsSupervision Documentation Retention

Coverage Summary

Overview: This CareSource policy (Applied Behavior Analysis for Autism Spectrum Disorder - AR PASSE) defines medical necessity, documentation, provider qualifications, initial and continuing authorization, supervision, telehealth, exclusions, and recordkeeping requirements for ABA services for Arkansas PASSE members. Policy Title: Applied Behavior Analysis for Autism Spectrum Disorder (ASD). Policy Number: MM-1227. Payer: CareSource. Effective Date: 2024-06-01. Status: CURRENT (Note: policy archived with end date 2024-12-31 per revision history). The policy is derived from clinical guidelines, state DHS requirements, and CareSource medical policy standards and requires medical necessity review for initial and ongoing ABA services.

Quick facts / thresholds

Authorization IntervalEvery 6 months

Behavioral Assessment LimitGenerally not to exceed 8 hours every 6 months (unless additional justification provided)

Minimum RBT Supervision>= 5% of ABA service hours per month

Clinical Record RetentionProfessional records: at least 10 years after last date of service

Supervision Documentation RetentionSupervision records: maintain for minimum of 7 years

Initial Authorization Criteria

Continuation Authorization Criteria

Discontinuation / Titration Criteria

Provider Qualifications, Supervision & Documentation

Documentation Required

Required Treatment and Progress Documentation

Maintain and submit complete treatment and progress records for all ABA services. Required elements include a current individualized treatment plan; signed consent by parent/legal guardian; dated service-level entries with start/stop times; name, title and dated signature of the individual providing each service; progress updates describing improvement or lack thereof; and supervision records. Retain professional records for at least 10 years and supervision documentation for a minimum of 7 years.

Current individualized treatment plan (includes SMART goals, frequency/hours/week, duration, discharge plan)
Signed consent by parent/legal guardian
Dated service entries with actual start and stop times and specific services rendered
Provider name, title, and dated signature on each entry
Progress updates showing improvement or lack of progress
Supervision records as required by policy
Record retention: professional records >= 10 years; supervision documentation >= 7 years

Telehealth Provision

Exclusions and Not Covered Services

Denial Risk

Risk of Denial for Noncompliance or Missing Documentation

Failure to provide required documentation or noncompliance with policy may lead to audits, post-payment review, recovery of identified overpayments, prepayment review, and denial of payment. CareSource may request supervision documentation and conduct medical review to verify services and payment limits.

Claims may be subject to post-payment data analysis and medical review audits
Identified overpayments may be recovered
Providers may be subject to prepayment review
CareSource may request supervision documentation to substantiate services
Incomplete or missing documentation can result in denial or nonpayment

Coding

No specific procedure or billing codes listedmixed

No codes listed

Background & Definitions

Background: Autism Spectrum Disorder (ASD) is a DSM-5-TR neurodevelopmental disorder marked by deficits in social communication and restricted, repetitive behaviors that vary in severity and impact across contexts. Applied Behavior Analysis (ABA) is described in this policy as an evidence-based, flexible behavioral treatment that is individualized to member needs, teaches generalizable skills, and may be provided in multiple settings. CareSource follows Arkansas Code and Arkansas DHS guidance for ABA provision, requires documentation of a DSM-5-TR diagnosis and standardized assessment tools, and aligns services with state licensure/certification expectations for BACB-certified professionals. The policy emphasizes early initiation of ABA—ideally by age 2—with treatment goals and intensity individualized based on needs and progress, coordination with other therapies, and adherence to BACB standards for provider qualifications, supervision, and documentation. Telehealth may be used for caregiver training and, when medically necessary, for 1:1 ABA delivery with supporting documentation and a service plan.

Term	Definition
Applied Behavior Analysis (ABA)
Design, implementation, and evaluation of environmental modifications by a board-certified behavior analyst using behavioral stimuli and consequences to produce socially significant improvement in behavior, including direct observation, measurement, and functional analysis of the relationship between environment and behavior.
Person Centered Service Plan (PCSP)
A member's total plan of care made in consideration of member-specific needs, strengths, and a crisis plan.
SMART Goals
Specific, Measurable, Attainable, Relevant, Time-bound goals used in treatment planning.
Independent Practitioner
All ABA services must be provided by a Behavior Analyst Certification Board (BACB)-certified behavior professional/paraprofessional (BCBA, BCBA-D, BCaBA, RBT as applicable).

Evidence and references: The policy cites multiple clinical guidelines, systematic reviews, MCG evidence reviews, BACB materials, UpToDate, CDC guidance, Hayes and other evidence assessments, and peer-reviewed literature supporting the use of ABA for ASD. See the policy reference list for full citations.

Actions for Providers

Prior Authorization

Initial and Continuing Authorization Required

Medical necessity review and authorization are required for initial ABA services and for continuation every 6 months. Submit documentation including definitive ASD diagnosis, standardized diagnostic tools or recent provider documentation, initial behavior identification assessment by a BCBA, and a detailed initial treatment plan that supports requested hours. Continuation requests must include updated progress reports using the same measurement modes and documentation of caregiver involvement or, if inadequate progress, assessment of reasons and modifications.

Definitive ASD diagnosis and supporting standardized diagnostic assessments (e.g., ADOS, ADI-R, CARS-2) or recent documentation if >24 months
Initial behavior identification assessment by a fully credentialed BCBA
Detailed individualized initial treatment plan (goals, frequency/hours/week, duration, prescription of hours requested, coordination with other services)
Updated progress reports and assessment scores for continuation
Authorization interval: every 6 months

Denial Risk

Risk of Denial for Noncompliance or Missing Documentation

Revision History

01/04/2023revised

Policy revised with additions including definition of PCSP and PSSP, revised initial ABA treatment plan and parent/caregiver involvement; policy restructured for clarity and telehealth exclusions removed.

03/29/2023revised

Annual review and additional revisions approved at committee; background and sections updated (including removal of telehealth exclusions and addition of sections VII and X).

12/31/2024archivedLatest

Policy Summary

PayerCareSource

PolicyApplied Behavior Analysis for Autism Spectrum Disorder-AR PASSE- MM-1227

Policy CodePolicy MM-1227

Change TypeRevisedArchived

Effective DateJun 1, 2024

Next Review Date

SourceLink

On This Page

Documentation Required

Supervision Documentation Requirements

Document supervision activities for all supervised staff. Supervision records must include dates and duration of supervision, dates of direct observation, supervision format, names of supervisors, proof of supervisor relationship to the client, summaries of supervision activity (including progress toward goals and interventions/plans of care), and dated signatures of supervisor and supervisee.

Dates and duration of supervision
Dates of direct observation
Supervision format (one-on-one, group)
Names of supervisors and proof of supervisor relationship to the client
Summary of supervision activity: progress toward goals, discussion of independent hours and feedback, interventions/plans of care
Dated signatures of supervisor and supervisee

Billing Rule

Medicaid Payer of Last Resort

Medicaid is always the payer of last resort. When a member has other insurance, the primary payer must provide evidence of its determinations; CareSource will not pay more than Medicaid rate totals.

Medicaid pays only after primary insurance has been applied
Primary payer determinations/evidence must be provided for consideration
CareSource will not pay beyond Medicaid rate totals

Noncompliance or missing documentation can trigger audits, post-payment review, and recovery of overpayments; CareSource may perform prepayment review and request supervision records. Providers should ensure all required records are maintained and submitted to avoid denials or repayment demands.

Post-payment data analysis and medical review audits possible
Recovery of identified overpayments may occur
Prepayment review may be initiated
CareSource may request supervision documentation to substantiate claims

Billing Rule

Medicaid Payer of Last Resort

When other insurance exists, Medicaid is payer of last resort; providers must coordinate with primary payers and provide evidence of primary payer determinations. CareSource will limit payment to Medicaid rate totals when primary insurance applies.

Medicaid pays after primary insurance (payer of last resort)
Provide primary payer determinations/evidence when other insurance exists
CareSource will not pay more than Medicaid rate totals

Policy archived and is no longer active as of 2024-12-31.