ModifiedCentenePolicy CP.BH.104

Applied Behavior Analysis

Defines clinical background, practice principles, coding implications, and historical revisions related to Applied Behavior Analysis services for members/enrollees, including telehealth and intensity considerations; affects providers delivering ABA for autism spectrum disorder.

Policy Summary

PayerCentene

PolicyApplied Behavior Analysis

Policy CodePolicy CP.BH.104

Change TypeMultiple material and operational revisions

Effective Date

Next Review Date

Key ActionSubmit prior authorization with a recent comprehensive diagnostic evaluation, behavior and skills assessments, and an individualized treatment plan specifying requested hours and justification.

SourceLink

POLICY UPDATE CHANGES

Updated guidance that intensity of ABA services should be individualized and not a uniform 30-40 hours per week; decisions to be made by a qualified behavior analyst considering goals, other services, learning rate, and family input.

Changed Comprehensive ABA intensity range from 25-40 hours to 30-40 hours.

Added telehealth practice parameter references and guidance that telehealth supplements rather than replaces in-person ABA services.

Added CPT, HCPCS and behavioral health codes relevant to ABA and related assessments/services (97151-97158, 0362T, 0373T, H0031, H0032, H0046, H2012, H2014, H2019, S5110, S5111).

Added requirement for a comprehensive diagnostic evaluation (CDE) and clarified timeframes and documentation requirements for CDEs.

Revised treatment hour limits to not exceed six hours per day up to 30 hours per week, with provisions for clinical justification beyond these limits.

Distinguished maladaptive behavior assessments from skills acquisition assessments and required behavior assessment completion by a BCBA or equivalent.

Added a dedicated crisis plan requirement and detailed school-based criteria, transition planning, and discharge considerations.

Added and updated HCPCS codes relevant to ABA and behavioral health services.

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30-40Comprehensive ABA weekly intensity range

<=30/wkStandard max treatment intensity

97151-58Common ABA CPT codes listed

HCPCS setAdded behavioral health procedure codes

PermittedTelehealth modality

Coverage and Medical Necessity

Medical Necessity Criteria for ABA

Covered when ALL of the following are met and individualized treatment planning is documented:

Diagnostic and assessment: ASD diagnosis and comprehensive diagnostic evaluation per DSM-5-TR and policy requirements; objective assessments and baseline descriptions to inform treatment goals.

See DSM-5-TR severity levels and requirement for comprehensive diagnostic evaluation.

Individualized treatment plan: A behavior-analytic treatment plan detailing targeted goals, number of service hours (direct, group, supervision), and rationale considering age, school attendance, other services, learning rate, and family priorities.

Plan should align with assessments and be current per professional/state standards.

Qualified personnel: Services recommended and overseen by qualified licensed professionals and qualified behavior analysts with a supervision infrastructure described in policy.

Includes direct training of caregivers and case supervision by a behavior analyst.

Data-driven practice: Use of objective measurement, ongoing data collection and analysis to inform adjustments and progress toward treatment goals.

Consistent, ongoing objective data analysis is required.

Intensity determination: Intensity of ABA services individualized; no uniform weekly hours mandated; a qualified behavior analyst determines weekly hours based on number/type of goals, other services, client learning rate, and family input.

Reflects National Academies recommendation that intensity be individualized rather than a uniform 30-40 hours per week.

Initial and continuation ABA coverage criteria

Covered when ALL of the following are met

Diagnostic criteria: Diagnosis supported by a Comprehensive Diagnostic Evaluation (CDE) including at least one primary clinician assessment tool and one parent/caregiver tool; CDE generally within 12 months of the authorization request or meets specified reevaluation conditions if older.CDE within 12 months unless specified conditions met

Tools and recency requirements are specified in policy.

Assessment requirements: Separate maladaptive behavior and skills acquisition assessments completed by a Board Certified Behavior Analyst (BCBA) or equivalent provider, including direct observations using continuous and discontinuous procedures and visual representation of assessment results.

If Vineland is used as a caregiver report, an additional direct skills assessment is required.

Treatment plan and hours: Individualized treatment plan with goals, crisis plan, parent/caregiver training (2–4 goals), coordination of care, transition and discharge planning; treatment intensity generally does not exceed six hours per day up to 30 hours per week unless clinical documentation justifies additional hours.

The policy removed prior explicit requirements that certain medical conditions (for example, historical lists such as neurological disorder, lead poisoning, or primary speech or hearing disorder) be specifically ruled out before ABA is considered. These removed items are now treated as implied clinical considerations within comprehensive diagnostic and assessment processes rather than as standing, discrete preconditions for coverage.

The policy no longer includes the former statement that the member must be "medically stable and does not require 24 hour medical/nursing monitoring or procedures provided in a hospital level of care." Operationally, this means authorization and clinical review should focus on individualized assessment and treatment setting safety rather than a blanket exclusion tied to inpatient-level medical needs.

Coverage of services described in this policy is subject to the exclusions, limitations, and terms specified in the member's coverage documents (for example, evidence of coverage, certificate of coverage, policy, or contract of insurance). Those benefit-level documents govern final coverage determinations and may impose additional constraints beyond the clinical policy.

Inclusion of a procedure or HCPCS/CPT code in this policy is for informational purposes only and does not guarantee coverage. Coverage for a specific code depends on meeting the policy's medical necessity criteria and any applicable payer, state, or plan-level coding rules; providers should verify current coding guidance prior to claim submission.

Services are considered not medically necessary when documentation demonstrates a lack of clinically significant progress despite adequate implementation of the treatment plan and caregiver training. When progress is not shown, continuation of ABA is not supported by the policy and should be denied or discontinued unless clear, documented justification demonstrates a reasonable expectation of benefit.

Procedure and Billing Codes

ABA CPT/Temporary CodesCPT

97151	Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non- face-to-face analyzing past data, scoring/ interpreting the assessment, and preparing the report/treatment plan.
97152	Behavior identification-supporting assessment, administered by one technician
97153	Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes.
97154	Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes.
97155	Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes.
97156	Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes.
97157	Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes.
97158	Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes.
0362T	Behavior identification supporting assessment, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior.
0373T	Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior.

Behavioral Health / HCPCS CodesHCPCS

H0031	Mental health assessment, by nonphysician.
H0032	Mental health service plan development by nonphysician.
H0046	Mental health services, not otherwise specified.
H2012	Behavioral health day treatment, per hour.
H2014	Skills training and development, per 15 minutes.
H2019	Therapeutic behavioral services, per 15 minutes.
S5110	Home care training, family; per 15 minutes.
S5111	Home care training, family; per session.

Added HCPCS codesHCPCS

H0031	Mental health assessment, by non-physician
H0032	Mental health service plan development by non-physician
H0046	Family training and counseling for child/adolescent mental health
H2012	Behavioral health day treatment, per 15 minutes
H2014	Skills training and development, per 15 minutes
H2019	Therapeutic behavioral services, per 15 minutes
S5110	Behavior management services, per 15 minutes
S5111	Behavior management, per 15 minutes

Comprehensive ABA weekly intensity — numeric key/value

Weekly intensity range30-40 hours per week (Comprehensive ABA) — updated from prior 25-40 hours

Policy rationaleChange reflected in policy revision notes to align intensity range with updated guidance and operational expectations

Use in treatment planningDocument number of weekly service hours in individualized treatment plan consistent with this range unless clinically justified

Prior Authorization, Documentation, and Provider Requirements

Note

Coding inclusion is informational

Coding references in this policy are provided for informational purposes only. Inclusion or omission of a code does not guarantee coverage. Providers must consult current CPT/HCPCS manuals, state-specific coding guidance, and payer billing requirements prior to claim submission.

CPT and HCPCS codes are informational; verify coverage with the member's benefit document and state guidance.

Denial Risk

CDE recency and assessment tool mismatch

The Comprehensive Diagnostic Evaluation (CDE) and assessment tools must be current and consistent with the policy requirements. If the CDE is older than three years but less than five years, specific conditions apply; if required assessment tools are missing or do not match the diagnosis, prior authorization may be delayed or denied.

Ensure at least one primary clinician tool and one parent/caregiver tool are included with the CDE.
If the CDE is >3 years and <5 years, meet the policy's specified conditions for acceptance.

Clinical Background and Evidence

Applied Behavior Analysis (ABA) is an evidence-based treatment approach for autism spectrum disorder that uses objective assessment, measurement, and functional analysis to identify the relationships between environment and behavior. ABA interventions aim to increase adaptive skills and reduce behaviors that interfere with learning and independence through behavior-analytic methods, environmental modifications, systematic teaching of small skill units, caregiver training, and ongoing data-driven decision-making. Services may be delivered across settings (home, clinic, school, community) and modalities (in-person, with telehealth as a supplemental option) and should be individualized by a qualified behavior analyst based on goals, learning rate, other services, and family priorities.

Key Terms and Assessment Standards

Core characteristics of ABA

Objective assessmentAn objective assessment and analysis of the person's condition using direct observation and appropriate measurement

Context and valueUnderstanding the context of the behavior and its value to the person, caregivers, family, and community

Promotion of dignityPromote the person's dignity throughout assessment and treatment

Behavior analysis principlesUtilization of principles and procedures of behavior analysis to improve health, skills, independence, quality of life, and autonomy

Ongoing data-informed decisionsConsistent, ongoing, objective data collection and analysis to inform clinical decision-making

ASD severity levels (DSM-5-TR)

Setting and Intensity Level Criteria

Outpatient / community-based ABA — level-of-care criteria (operational nodes)

Admission considerations: Services may be provided in home, clinic, school, community, and via telehealth (telehealth intended to supplement in-person care). Intensity and level of services are determined by individualized assessment and the treatment plan.

Selection of telehealth vs in-person should be individualized based on needs, caregiver availability, and environmental supports; refer to state telehealth allowances and CASP parameters.

Continued services: Ongoing objective data demonstrating progress toward treatment goals; documentation of ongoing caregiver training and supervision; treatment plans reviewed per policy frequency requirements; reasonable expectation of benefit for continued services.

Policy expects gradual step-down/transition planning and periodic reassessment as part of continued care.

Outpatient ABA / community-based — additional level-of-care criteria nodes

Practice Elements and Clinical Criteria

ABA practice elements — practice elements and treatment principles

Practice elements and treatment principles that should be present in ABA services:

Core ABA elements: Objective assessment and measurement of behavior; understanding behavior context and value; promotion of dignity; application of behavioral principles to improve health and independence; ongoing data-informed clinical decision-making.

These core characteristics are expected across assessment and treatment phases.

Essential practice elements: Comprehensive assessment with baseline descriptions; collaboration with client/caregivers; focus on small units of behavior building to larger skills; direct caregiver training; consistent treatment protocols across environments; supervision infrastructure for case oversight.

Emphasis on measurable outcomes, generalization, and fidelity of implementation.

ABA clinical criteria — ABA-specific coverage criteria and clinical thresholds

ABA-specific coverage criteria

Delivery Modalities and Service Types

ABA (in-person, telehealth, technician-delivered, family guidance, group) — modality criteria

Modalities: In-person and telehealth service delivery, individual technician-delivered services, protocol-based treatments, family guidance, and group services as described by CPT and HCPCS codes.

Telehealth is intended to supplement—not replace—in-person services; modality selection should be individualized based on needs and caregiver availability.

Applied Behavior Analysis (ABA) — modality overview

Modality overview: Applied Behavior Analysis services may be delivered across multiple modalities (in-person, telehealth adjunct, technician-delivered sessions, family guidance, and group formats) consistent with CPT/HCPCS code descriptions and policy documentation requirements.

Documentation and clinical justification must support the selected modality and any deviations from standard intensity or supervision thresholds.

Intensity, Frequency, and Supervision Limits

Comprehensive ABA direct service intensity range

Direct service weekly range30-40 hours per week (Comprehensive ABA direct service intensity range)

Policy revision noteRange updated from prior 25-40 hours to 30-40 hours as part of policy changes

Treatment planning implicationUse this range as expected comprehensive direct service hours when documenting treatment plans unless clinical justification indicates otherwise

ABA direct therapy — standard intensity limits

Daily maximumStandard ABA direct therapy: does not exceed 6 hours per day

Weekly maximumStandard ABA direct therapy: does not exceed 30 hours per week

Policy Summary

PayerCentene

PolicyApplied Behavior Analysis

Policy CodePolicy CP.BH.104

Change TypeMultiple material and operational revisions

Effective Date

Next Review Date

SourceLink

On This Page

<=6 hours/day; <=30 hours/week (unless justified)

Supervision via Adaptive Behavior Treatment with Protocol Modification for at least 2 hours per week or 10% of direct service; supervision generally should not exceed 20% of direct service hours unless clinically justified.

Progress and continuation: Continuation requires documented clinically significant progress or reasonable expectation of benefit, updated behavior assessment when requested, documentation of session attendance (note if <80%), ongoing parent/caregiver training, and coordination of care; inability or unwillingness of caregivers to implement interventions must be documented.Attendance >=80% expected; caregiver training goals documented

Transition planning and titration plan guidance and documentation requirements are detailed in policy.

Prior Authorization

Coverage decisions subject to plan terms

Coverage determinations and the administration of benefits are made in accordance with the member's coverage documents and applicable law. This clinical policy is a guide to medical necessity and does not guarantee payment. Providers must follow all terms, conditions, exclusions, and limitations in the member's evidence of coverage or contract.

Coverage decisions subject to exclusions, limitations, and applicable state/federal requirements.
This policy does not replace the member's coverage document — refer to plan benefits for coverage determination.

Documentation Required

Providers must follow member coverage terms and administrative requirements

Providers must adhere to the terms, conditions, exclusions, and limitations of the member's coverage document when requesting services. This policy does not create provider obligations beyond those established by the contract and applicable law. Providers are responsible for exercising professional judgment and for the accuracy and completeness of documentation submitted for authorization and claims.

Follow member-specific EOC/contract and any Health Plan-level administrative policies.
Providers are independent contractors and must ensure documentation meets plan and state requirements.

Note

Telehealth permitted as adjunct to in-person services

Telehealth may be used as an adjunctive modality to in-person Applied Behavior Analysis services to improve access to care. Telehealth is not intended to replace in-person services; clinical decisions about telehealth use should be individualized based on caregiver availability, environmental supports, and the member's needs. Providers should follow state telehealth allowances and CASP telehealth practice parameters.

Telehealth is supplemental to, not a replacement for, in-person ABA services.
Select telehealth vs in-person delivery based on individual needs, caregiver availability, and environmental support; follow state regulations and CASP guidance.

Note

Provider operational guidance (unspecified)

Operational and provider-specific instructions (e.g., additional submission steps, contact points, or state-specific modifiers) may be required but are not specified in this excerpt. Providers should consult the applicable Health Plan provider resources, state requirements, and prior authorization portals for any operational guidance not contained here.

Check the Health Plan's provider portal or contact for unspecified operational requirements.
Ensure any state-specific authorization or billing modifiers are applied as required.

Level 1 (Requiring support)Deficits in social communication cause noticeable impairments without supports; difficulty initiating interactions; restricted/repetitive behaviors cause significant interference in one or more contexts

Level 2 (Requiring substantial support)Marked deficits in verbal and nonverbal communication; social impairments apparent even with supports; limited initiation of interactions; restricted/repetitive behaviors obvious across contexts

Level 3 (Requiring very substantial support)Severe deficits in social communication and restricted/repetitive behaviors causing severe impairments in functioning, minimal initiation, and great distress with changes

CDE — Comprehensive Diagnostic Evaluation

DefinitionComprehensive Diagnostic Evaluation (CDE): a diagnostic interview/evaluation documenting ASD diagnosis using at least one primary clinician assessment tool and one parent/caregiver assessment tool

Recency requirementCDE should generally be conducted within 12 months of the authorization request; specified reevaluation conditions apply if older

PurposeCDE provides diagnostic support and baseline information to inform individualized ABA treatment planning

Behavior and skills assessments — definitions

Maladaptive behavior assessmentA distinct assessment to identify target maladaptive behaviors, completed by a BCBA or equivalent, including direct observation and measurement (continuous and discontinuous) and visual representation of results

Skills acquisition assessmentA separate assessment identifying functional skill deficits to guide skill-building goals; if Vineland is used, an additional direct skills assessment is required

Assessment requirementsBoth assessments must include direct observation data and be completed by qualified personnel per policy (BCBA or equivalent)

Definition of 'Health Plan' used in policy

Health Plan definition'Health Plan' means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan's affiliates

Policy purposeClinical policy provides guidance to assist coverage decisions and administering benefits but does not guarantee payment

ApplicabilityCoverage decisions are subject to the terms, conditions, exclusions, and limitations of the member's coverage documents and applicable law

Admission: Member has documented ASD diagnosis with required CDE and assessment tools; treatment goals and caregiver involvement are documented; member's behavior can be safely managed in the requested outpatient/home/community setting.

Policy includes school-based criteria and setting considerations for outpatient services.

Continued stay: Demonstrated clinical progress or a reasonable expectation of benefit; updated behavior assessment when requested; documentation of attendance and caregiver participation; transition/titration plan in place for step-down or discharge.

Includes documentation of percent scheduled successful sessions (note if attendance <80%).

Intensity limits: Standard ABA does not exceed six hours per day up to 30 hours per week; additional hours require clinical justification meeting specified documentation criteria in policy.<=6 hrs/day; <=30 hrs/week

Clinical documentation criteria for hours beyond limits are detailed in policy (e.g., justification components for additional hours).

Supervision: Adaptive Behavior Treatment with Protocol Modification required for at least 2 hours per week or 10% of direct service; supervision generally should not exceed 20% of direct service hours unless clinical documentation justifies otherwise.2 hrs/week or 10%

Policy revised prior vague 'supervision hours' language to specify these thresholds.

Parent/caregiver training: Two to four parent/caregiver treatment goals required at initiation and continued caregiver training for continuation of services; document caregiver ability and participation and note when caregivers are unwilling or unable to implement interventions.2-4 goals

Specified for both initiation and continuation criteria.

Crisis planning and coordination: An individualized crisis plan is required as part of the treatment plan, and coordination of care with school and other providers should be documented.

Transition planning and discharge considerations should involve the care team and a gradual step-down in services.

ExceptionsRequests for intensity beyond these limits require clinical justification and specified documentation per policy