Prior Authorization Required

Prior authorization approval for ABA services must be obtained when required by the plan prior to billing. Billed units not fully supported by documentation may be subject to payment denial or recoupment.

• Applies to all ABA service codes when the plan requires prior authorization.

Required administrative and signature elements

Clinical documentation must be reviewed and updated regularly and include legible signatures and printed names for the member/enrollee, legal guardian (if applicable), the rendering clinician/technician, and the supervising practitioner/Qualified Healthcare Provider when applicable. Documentation must be clear and legible.

• Signature and printed name of member/enrollee or legal guardian on each page as applicable.
• Signature of qualified rendering provider/technician on service notes and discharge summaries.

Service activity note content

Service activity notes must be completed prior to claim submission and include comprehensive identification, timing, service specifics, and treatment detail to support billed services.

• Provider organization name and rendering provider/technician clearly visible at top of each note.
• Member/enrollee name (legal name and preferred name if different) on each page; DOB or unique identifier.
• Exact date and start/end time of session; location of services; type of service with applicable code.
• If note creation date differs from date of service, include date of note creation and rationale.
• Pauses in services with exact pause/resume times; summary of techniques used and direct treatment provided.
• If rendering codes 0373T, 97155, H0032 and/or 97158 are used, include list of protocol modifications or rationale that no modifications were needed and clinical justification; indicate frequency and duration of protocol modification as required.

Discharge summary requirements

When a member/enrollee no longer meets medical necessity criteria, the discharge summary must document the clinical rationale and continuity actions.

• Referrals provided.
• Rationale/reason for discharge with supporting progress summary.
• Signature of qualified rendering provider.
• Signature of caregiver.
• Date of discharge.

Protocol modification documentation and audit risk

Providers must document protocol modifications per policy requirements; lack of adequate documentation to support protocol modification or billed units (including 97153/97154) for the authorization period may result in denial or recoupment. Protocol modification documentation should reference original notes when supplementing and include completion date and legible name/signature/credentials of the clinician.

• All 97153/97154 units billed for the member during a six-month authorization that are not supported by required protocol modification documentation are subject to denial or recoupment.
• Notes added as addenda must clearly reference the original clinical note and include date of completion and legible name, signature, and credentials.
• Protocol modification must occur at least two hours per week or 10% of direct service hours, whichever is greater, and generally no more than 20% of direct service hours unless clinically justified; at least monthly one-on-one service delivery with the member by the ABA supervisor is required when applicable.

PHI / HIPAA documentation note

Documentation that contains protected health information (PHI) must be handled in compliance with HIPAA and applicable state privacy laws; telehealth documentation must include HIPAA compliance verbiage where applicable.

• Ensure PHI is stored, transmitted, and disclosed in accordance with HIPAA.
• Include required telehealth/HIPAA compliance statements in documentation when services are delivered via telehealth.