Prior Authorization Required

Prior authorization is required for initiation and reauthorization of Applied Behavior Analysis (ABA) services. Prior authorization requests must include a BCBA-completed behavioral assessment (or equivalent as allowed by state law), an individualized treatment plan that aligns with the behavior assessment, and supporting documentation demonstrating medical necessity per this policy.

• Prior authorization required for ABA service codes (see CPT/HCPCS descriptions): 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T.
• Reauthorization: updated behavior assessment and treatment plan are required at least every six months (or sooner as clinically or state required).

Coverage Document and Regulatory Compliance

Documentation supporting prior authorization and continued coverage must demonstrate compliance with state and plan-specific coverage documents and all applicable legal/regulatory requirements. Coverage determinations are governed by the member's benefit document (EOC, contract, state Medicaid plan) and applicable federal/state rules; when conflicts exist, Medicaid/Medicare rules prevail where applicable.

• Providers must verify member eligibility and benefit limits prior to service authorization.
• Coverage is subject to terms, conditions, exclusions, and limitations of the member's coverage documents and applicable Health Plan administrative policies.

Required Documentation for ABA Services

Providers must submit required documentation with authorization requests and retain documentation to support claims. Required documentation includes a confirmed ASD diagnosis (per DSM or state-defined criteria), a comprehensive diagnostic evaluation within the past five years (per state-defined ABA criteria), the behavior identification/supporting assessment, and an individualized treatment plan with measurable goals, timelines, and transition/discharge planning.

• Confirmed ASD diagnosis (DSM or state-defined equivalent).
• Comprehensive diagnostic evaluation conducted within the past five years.
• Behavior identification/supporting assessments (e.g., CPT 97151, 97152, 0362T) and any applicable functional behavioral assessments (FBA) when problem behaviors are present.
• Individualized treatment plan with measurable, targeted outcomes, timelines, caregiver training plan, supervision plan, treatment hours justification, settings rationale, and transition/discharge criteria.

Behavior Identification and Assessment Must Be Submitted

Documentation submitted must include behavior identification and assessment reports that support the treatment plan and authorization request. Assessments must provide qualitative and quantitative data collected across settings, describe changes over time (including graphs/data as applicable), and include data sources such as record review, interviews, rating scales, direct observation, and caregiver/teacher input.

• Behavior identification assessment (CPT 97151) or equivalent report including analysis and treatment recommendations.
• Supporting assessments (CPT 97152, 0362T) and technicians' assessment reports when applicable.
• Evidence that assessments informed the individualized treatment plan and documented baseline measures and progress metrics.

Policy Use and Provider Responsibilities

Providers, members, and their representatives are bound by this clinical policy when providing services or submitting claims. Providers are independent contractors and remain responsible for obtaining prior authorization, maintaining complete records, and ensuring services are appropriate and not duplicative of other covered services. Unauthorized use or distribution of this policy is prohibited.

• Providers must follow plan billing rules and authorization procedures; failure to provide required documentation may result in denial of authorization or claims.
• For Medicaid members, state Medicaid provisions take precedence when they conflict with this policy.
• Providers should confirm applicability of any Medicare NCDs/LCDs for Medicare members prior to applying policy criteria.

Consideration of Less Intensive Alternatives

Prior to authorization and during reauthorization, providers must document consideration of less intensive or alternative services (e.g., school-based supports, speech/OT, psychotherapy, case management) and explain why ABA is the most appropriate and medically necessary service for the member.

• Document evaluations for other services and multidisciplinary coordination (school, prescribers, speech/OT, behavioral health).
• If less intensive options are available or more appropriate for specific goals, document rationale for continued ABA or transition planning.