Currentculinary health fundPolicy N/A

Applied Behavior Analysis (ABA) therapy coverage criteria for pediatric members

Defines benefit coverage, provider and patient eligibility, prior authorization, and service limits for ABA therapy for pediatric members of the Culinary Health Fund.

Policy Summary

Payerculinary health fund

PolicyApplied Behavior Analysis (ABA) therapy coverage criteria for pediatric members

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionAfter the initial assessment, submit the patient's treatment plan to Nevada Health Solutions for prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2-5 yrscovered pediatric age range

>=11 mominimum PMA

30 hrs/wkmax hours/week

$10copay

Semi-annualreview frequency

Coverage and Eligibility Criteria

Policy Summary

Payerculinary health fund

PolicyApplied Behavior Analysis (ABA) therapy coverage criteria for pediatric members

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionAfter the initial assessment, submit the patient's treatment plan to Nevada Health Solutions for prior authorization.

SourceLink

On This Page

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Initial Coverage Criteria

Covered when ALL of the following are met

Eligibility and provider requirements: Child is at least 2 years old and younger than 6 years old; has a valid diagnosis of Autism Spectrum Disorder (ASD); has a prorated mental age (PMA) of at least 11 months. Therapy is ordered by a pediatrician, child psychiatrist, child psychologist, or another provider operating within the scope of his or her state license. Supervising provider is certified and licensed by the BACB as a BCBA or BCBA-D or is another provider operating within the scope of his or her state license. The individual providing ABA therapy must be trained and certified by the BACB (e.g., BCaBA or RBT) or be another provider operating within the scope of his or her state license.

Includes requirement for parent/caregiver training and semi-annual review of plan and notes; benefits paid up to maximum hours determined by treatment plan, not to exceed 30 hours/week.

Coverage for Applied Behavior Analysis (ABA) therapy ends when either: (1) the child reaches 6 years of age (at which point school-based services become available), or (2) any of the eligibility or provider criteria required for coverage are no longer met. Examples of criteria that would end coverage include loss of an ASD diagnosis, failure to meet the minimum prorated mental age, or lack of an appropriately licensed ordering or supervising provider.

The Fund may deny coverage for future ABA services when there is insufficient demonstration of clinical benefit or when the member or family does not adhere to the prescribed program. Specifically, future therapies may not be considered a covered expense if the patient is not demonstrating, to the Fund's satisfaction, improvement, or if the child or his or her parents are not adhering to the treatment program (including required caregiver participation and agreed treatment plans).

Procedure Codes and Limits

ABA CPT CodesCPT

0359T	Behavior identification assessment
0360T	Observational behavioral follow up assessment; first 30 minutes
0361T	Observational behavioral follow up assessment; each additional 30 minutes
0362T	Exposure behavioral follow up assessment; first 30 minutes
0363T	Exposure behavioral follow up assessment; each additional 30 minutes
0364T	Adaptive behavior treatment by protocol; first 30 minutes
0365T	Adaptive behavior treatment by protocol; each additional 30 minutes
0366T	Group adaptive behavior treatment by protocol; first 30 minutes
0367T	Group adaptive behavior treatment by protocol; each additional 30 minutes
0368T	Adaptive behavior treatment with protocol modification; first 30 minutes

1–10 of 14

1/2

Prior Authorization Requirements for ABA CPT CodesCPT

0359T	Prior Authorization Required? = NO
0360T	Prior Authorization Required? = YES
0361T	Prior Authorization Required? = YES
0362T	Prior Authorization Required? = YES
0363T	Prior Authorization Required? = YES
0364T	Prior Authorization Required? = YES
0365T	Prior Authorization Required? = YES
0366T	Prior Authorization Required? = YES
0367T	Prior Authorization Required? = YES
0368T	Prior Authorization Required? = YES

1–10 of 14

1/2

Maximum weekly therapy hours

Maximum weekly therapy hoursBenefits paid up to the maximum number of hours determined necessary under the treatment plan, not to exceed 30 hours of ABA therapy per week.

ApplicabilityLimit applies to total ABA therapy hours across providers and settings per week.

DeterminationHours authorized are based on the applicable treatment plan and clinical necessity.

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for the ABA CPT/HCPCS codes listed in the policy after the initial assessment. The provider must contact Nevada Health Solutions (NHS) with the patient’s treatment plan following the initial assessment to obtain prior authorization.

Provider must contact Nevada Health Solutions (NHS) after initial assessment to request prior authorization.
Applicable CPT/HCPCS codes (e.g., 0360T–0369T, 0370T–0372T) require prior authorization; 0359T does not require prior authorization.

Documentation Required

Required Treatment Plan Components

The treatment plan submitted for authorization must include specific, measurable elements and documentation of family involvement and progress monitoring. Parent/caregiver training and support must be incorporated into the plan, and treatment intensity/duration should be individualized.

Specific target behaviors and skills to be addressed.
Explicit and measurable goals.
Parent/caregiver training and support included.
Regular interval assessment of progress (semi-annual review of treatment notes and plan).
Treatment intensity and duration customized to the child’s needs, not to exceed 30 hours/week.

Denial Risk

Denial Risk for Nonadherence or Lack of Progress

If the child is not demonstrating improvement to the Fund’s satisfaction, or if the child or parents/caregivers are not adhering to the treatment program, future therapies may not be considered a covered expense. Coverage will also cease when the child reaches 6 years of age or if other eligibility criteria are no longer met.

Failure to demonstrate improvement or lack of adherence may result in denial of future services or discontinuation of coverage.
Coverage terminates when the child reaches 6 years of age or if eligibility criteria (age, ASD diagnosis, supervising provider credentials, etc.) are not maintained.

Clinical Background

Applied Behavior Analysis (ABA) is provided to young children with Autism Spectrum Disorder (ASD) to target specific behaviors and skill development using individualized, measurable goals and caregiver training. The policy requires services be delivered under the supervision of a BACB-certified clinician (BCBA or BCBA‑D) with therapy delivered by BACB‑trained staff (e.g., BCaBA or RBT) or other providers operating within their state scope of practice. Treatment plans must incorporate parent/caregiver training, be pre‑certified, and have treatment notes and the plan reviewed on a semi‑annual basis. The Fund also limits benefits to the hours deemed necessary by the treatment plan, with a maximum of 30 hours per week.

Provider and Role Definitions

Supervising provider

Required qualificationSupervising provider must be certified and licensed by the BACB as a BCBA or BCBA-D.

Alternate supervisorsMay be another type of provider operating within the scope of his or her state license.

RoleResponsible for supervision of ABA services and inclusion in treatment plan and reviews.

ABA therapy provider

Acceptable providersIndividuals trained and certified by the BACB such as BCaBA or RBT.

State scopeMay also be another type of provider operating within the scope of his or her state license.

Supervision requirementMust provide therapy under a BACB-certified supervising provider (BCBA/BCBA-D) or equivalent within state scope.

Service Setting and Level of Care

Outpatient/ABA services

Outpatient ABA services are covered when the following outpatient-level criteria are met

Admission: Child aged >=2 and <6 years with valid ASD diagnosis and PMA >=11 months; therapy ordered by eligible provider; supervising provider BCBA/BCBA-D (or equivalent); treatment plan submitted and pre-certified as required; parent/caregiver training included.

After initial assessment the provider must contact Nevada Health Solutions (NHS) with the patient’s treatment plan for prior authorization of listed CPT codes.

Continued stay: Demonstrated improvement to the Fund's satisfaction; continued caregiver engagement and adherence to the treatment program; semi-annual reviews of treatment plan and treatment notes.

Services may be discontinued if criteria are not met; coverage ceases when child reaches 6 years of age or when eligibility/provider criteria are no longer met.

ABA Treatment Plan Requirements

ABA treatment plan criteria

ABA treatment and plan requirements

Treatment plan content: Treatment plan identifies specific target behaviors and skills to be addressed; lists explicit and measurable goals; includes parent/caregiver training and support; specifies treatment intensity and duration customized to the child’s needs and abilities; provides for regular interval assessment of progress.

Provider must submit the treatment plan to Nevada Health Solutions after the initial assessment for prior authorization as required for listed CPT codes; plan and treatment notes must be reviewed semi-annually.

Covered ABA Services

ABA (assessment and adaptive behavior treatment)

Service coding and prior authorization for ABA assessment and adaptive behavior treatment

Service coding: CPT/T-codes describe behavior identification assessment (0359T), observational and exposure follow-up assessments (0360T-0363T), adaptive behavior treatment by protocol (0364T-0365T), group adaptive behavior treatment (0366T-0367T), adaptive behavior treatment with protocol modification (0368T-0369T), family and multiple-family adaptive behavior treatment guidance (0370T-0371T), and group adaptive behavior treatment social skills (0372T). Many of these codes require prior authorization per the code list; 0359T does not require prior authorization.

After initial assessment the provider must contact Nevada Health Solutions with the patient’s treatment plan for authorization of codes that require prior authorization.

Visit Limits and Cost Sharing

ABA therapy hours

Weekly maximumMaximum 30 hours per week of ABA therapy.

Based on planHours authorized up to the maximum necessary under the applicable treatment plan.

CeilingBenefits will not exceed 30 hours/week even if treatment plan requests more.

ABA therapy visit/day

Per-day copay$10 copay per day of treatment, regardless of number of hours or number of ABA providers treating the dependent during that day.

Applies toEvery day on which ABA services are provided, regardless of duration or multiple providers.

Billing noteSingle daily copay applies even if multiple ABA sessions or providers occur the same day.