Certification Standards for Providers of Home Based Therapeutic Services (HBTS) (inclusive of ABA)
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Certification standards governing provision, scope, service components, prior authorization, and provider requirements for HBTS (inclusive of ABA) for children and adolescents with moderate to severe special health care needs in Rhode Island; applies to EOHHS-certified provider-agencies and Medicaid-enrolled clients.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
General coverage criteria
Covered when ALL of the following are met:
See Appendix 1 for definition of medical necessity
Clinical supervision allocation and progress reporting required
Initial Treatment Plan Approval
Covered when ALL of the following are met and documented in the Treatment Plan:
These items must be documented in the Treatment Plan and supported by referral/collateral information.
Adaptive Functioning Criteria
Functional impairment domains (one or more required):
At least one domain must be documented as impaired.
Treatment Intensity Criteria
Treatment intensity determination:
Provider-agency is responsible to justify hours as medically necessary; clinical supervision must be allocated per standards.
Initial Eligibility
Initial eligibility — Covered when ALL of the following are met and documented:
HBTS is not emergency care and may not be provided when CAITS/CFIT/EOS are in use.
Continuing Care
Continuing care — Treatment plan continued/reauthorized when ALL of the following apply:
Treatment Plans are approved for defined authorization periods with required progress reporting; clinical supervision must be maintained.
Discharge Criteria
Discharge — HBTS may be ended when ANY of the following are met:
Providers must follow agency policies for termination and provide required notifications.
Phase 1: Pre-Treatment
Phase 1 coverage conditions and intensity
Intensity: 2 hours/week provided by a licensed clinician; OT/PT/SLP clinicians may provide Pre-Treatment.
Phase 2: Specialized Treatment/Treatment Support
Phase 2 coverage and intensity rules
Clinical Supervisor oversight required; provider must document justification for continued Specialized Treatment in year 2 if >40%.
Phase 3: Treatment Support
Phase 3 coverage and intensity
Treatment Support emphasizes structure, supervision, guidance and redirection rather than intensive goal-directed intervention.
Phase 2 — Specialized Treatment/Treatment Support
Phase 2 coverage and intensity rules
Total Phase 2 intensity is capped at 20 hours/week.
Phase 3 — Treatment Support
Phase 3 coverage and intent
Phase 3 maintains functional gains at reduced intensity.
Phase 4 — Post-treatment
Phase 4 post-treatment rules
Service intended for termination/transition period; prior authorization required for consultation services.
Phase 5 — Extended HBTS eligibility
Phase 5 eligibility and coverage
Intensity: maximum 20 hours/week of Treatment Support with up to 50% Specialized Treatment if clinically indicated.
Service unit limits & qualifications
Service-specific unit limits and personnel qualifications
Provides direct support, functional assessments, and documentation; intensity 2 hrs/week when provided by licensed clinician.
Coordinates caregivers and collects data for reports.
Not the same person as Clinical Supervisor when specified; prior authorization required.
Responsible for Treatment Plan development and staff training; pattern of >30 hours/week by a supervisor requires EOHHS review.
EOHHS approval and agency-specific formal training required.
Clinical supervision hours documented separately.
HBTS is not intended to replace therapeutic services that are provided through an Individualized Education Program (IEP) or an Individualized Family Service Plan (IFSP), nor is it a substitute for required educational therapies. Specialty consultations within HBTS are designed to support practice of targeted skills and are not a substitution for necessary IEP/IFSP therapies.
HBTS is not intended to provide companionship or family respite and should not be delivered when higher‑level services such as Child and Adolescent Intensive Treatment Services (CAITS), Child and Family Intensive Treatment (CFIT), or Enhanced Outpatient Services (EOS) are in use. HBTS is an active therapeutic intervention and may not be used as a convenience or respite service.
HBTS will not be used as respite or childcare and is not a substitute for Private Duty Nursing, RN, or CNA responsibilities. Administration of medication and other licensed nursing tasks cannot be assigned to unlicensed HBTS workers; when nursing care is required the provider must arrange appropriate licensed nursing services.
Provider‑agencies may elect to decline a referral if there is a current history of prior restraints or a high likelihood of restraint events that would jeopardize safety. Agencies should obtain prior treatment histories and necessary releases so that risk and appropriateness of HBTS can be evaluated before accepting the case.
Occupational, Physical, and Speech/Language therapists who are employed by a Local Education Authority (LEA) may be subject to Department of Education or LEA regulations that limit or prohibit their participation as HBTS Treatment Consultants. Provider‑agencies must confirm potential conflicts of interest and compliance with DOE/LEA rules before engaging LEA‑employed clinicians.
Families who have received relevant outpatient services within the past 6 months may be exempt from beginning HBTS with the Phase 1 Pre‑Treatment consultation and, where appropriate, proceed directly to Phase 2 evaluation and services.
Services that are provided solely for convenience—such as transportation for convenience—or that are companionship or family respite are not medically necessary under HBTS. Any transportation included in a Treatment Plan must be clinically justified and directly tied to accomplishing approved treatment objectives.
HBTS is intended to provide intensive therapeutic supports and is not appropriate as a substitute for other covered intensive services (for example CAITS, CFIT, or EOS) or to serve as respite or childcare. Use of HBTS in place of these covered services may be subject to limitation, suspension, or termination.
EOHHS has authority to exclude or limit any service it determines to be not medically necessary, unsafe, experimental, or not generally accepted. Providers should anticipate oversight, site visits, and that EOHHS may place restrictions on amount, duration, and scope of HBTS services when warranted.
Procedure Codes, Units, and Limits
| Appendix 13 | Prior Authorization Procedure Codes (see Appendix 13 for full code list) |
| S9445 | Child Specific Orientation |
| H0046HO | Clinical Supervision - Master Level Clinician |
| H0046HP | Clinical Supervision – Doctoral Level Clinician |
| H0046 | Lead Therapy |
| H2014 | Specialized Treatment Consultation - OT/PT/SLP; Treatment Consultation |
| H2014HO | Treatment Consultation - Master Level Clinician |
| H2014HP | Treatment Consultation - Doctoral Level Clinician |
| T1016 | Treatment Coordination |
| T1013 | Interpretation |
Provider Requirements, Authorizations, and Documentation
Prior authorization required for HBTS reimbursement
Reimbursement for Home-Based Therapeutic Services (HBTS) requires prior authorization. For fee-for-service families, prior authorizations from each HBTS provider must be sent once a week as a batch form prior to the service start date.
Authorization required for additional ABA supports
Additional supports for ABA discrete trial interventions (for example, increased Clinical Supervision and Lead Therapy hours) require authorization from EOHHS or the family's insurance provider and are limited to ABA-recognized providers.
Prior authorization required for HBTS treatment plans
Prior authorization is required for HBTS treatment plans; Appendix 13 lists the procedure codes that require prior authorization.
Billing substantiation — document services in client record
All service billings must be substantiated in the client record; the client record is the basis for billing and documentation guidelines in Appendix 12 apply to Medicaid/EOHHS requirements.
Maintain and document clinical supervision during authorization
The provider-agency must maintain clinical supervision throughout a period of treatment authorization and document supervisory activities; any pattern of a Clinical Supervisor or Treatment Consultant providing more than 30 hours of service per week, unless approved by EOHHS, will be subject to review.
Expect EOHHS service limits and oversight
EOHHS may place limits on services (amount, duration, and scope) and exclude items or services determined not medically necessary or experimental; providers should expect EOHHS oversight including audits and site visits.
Follow consultation sequencing (Pre-, Treatment, Specialty, Post-Consultation)
Pre-Treatment Consultation may occur before direct services; Treatment Consultation and Specialty Consultation may occur before, during, and after HBTS to provide expertise and support to the treatment team.
Confirm prior intensified outpatient treatment was insufficient
HBTS is intended when intensified outpatient services have been insufficient; it is not emergency care and prior intensified outpatient services must have been insufficient before approving HBTS.
Ensure HBTS is appropriate relative to other intensive services
HBTS is not intended as emergency care and may not be provided when CAITS, CFIT, or EOS are being used; providers must ensure HBTS is appropriate relative to other available intensive services.
Referral acceptance may be declined for restraint history
Provider-agencies may decline referrals when there is a current history of prior restraints or a high likelihood of restraints; agencies should obtain prior treatment histories and releases as necessary.
Provider actions — comply with authorization, documentation, supervision, and billing rules
Provider actions summary: follow prior authorization, documentation, supervision, and eligibility requirements described throughout the HBTS standards; ensure all billing, recordkeeping, and clinical obligations are met.
Begin HBTS with Phase 1 Pre-Treatment then progress to Phase 2
Families generally begin with Phase 1 Pre-Treatment (unless exempt) and then proceed to Phase 2 Specialized Treatment; Phase 1 may continue up to 6 months to inform treatment planning.
Expect phased progression in Phase 2 — introduce Treatment Support in year 2
During Phase 2, year 1 services may be primarily Specialized Treatment; in year 2 Treatment Support should be introduced and may constitute up to 60% of hours unless there is sound clinical justification to continue predominantly Specialized Treatment.
Obtain physician prescription and create a measurable Treatment Plan
HBTS requires a physician's prescription and a Treatment Plan with defined, specific, and measurable goals and objectives; providers must obtain the prescription and document frequency and duration tied to medical necessity.
Use referral/collateral info and document treatment planning and medical necessity
Provider-agencies must use referral and collateral information (IEP/IFSP, provider contacts, records), maintain ongoing caregiver communication, obtain signed Treatment Plans from parents/caregivers/guardians, and substantiate medical necessity for requested HBTS hours.
Verify third‑party coverage and submit proof (Medicaid payer of last resort)
Providers must verify third-party commercial insurance coverage and provide proof; Medicaid is payer of last resort and providers must coordinate benefits accordingly.
Document diagnosis, individualized Treatment Plan, progress, and required notifications
Providers must document a recent formal diagnosis within two years, create individualized Treatment Plans with measurable goals, document active treatment progress, and maintain written policies and notifications for suspension/termination including 30-day family notification.
Maintain complete client records to substantiate billing and care
Client records must include initial and detailed assessments, comprehensive Treatment Plans, documentation of services and changes in status; all entries must be dated and authenticated and the client record is the basis for billing.
Document and review each restraint event; keep staff training records
Each restraint episode must be documented and reviewed by the Clinical Supervisor; staff training and certification in restraint techniques, First Aid, and CPR must be maintained in staff records.
Document clinical supervision with specified elements
Clinical supervision must be documented in writing and include child's name, date, recipients, place, duration, purpose/content, recommendations/follow-up, and supervisor signature; agencies must document supervisors' services and time allocation.
Maintain Treatment Plan and records available for EOHHS inspection
Providers must keep client records and Treatment Plans documenting medical necessity; EOHHS may inspect written records, clinical supervision notes, claims documentation, and other records during site visits and audits.
Include required documentation elements (assessments, notes, data, specialty forms)
Documentation must include consultation and supervision notes, functional assessments, Treatment Plans and goals, data collection on treatment responses, and specialty consultation forms for each relevant service and personnel role.
Prior authorization required for reimbursement
Reimbursement for HBTS requires prior authorization (PA); providers must obtain PA before billing for services.
Expected to accept Medicaid-eligible HBTS referrals
Provider-agencies are expected to accept referrals of Medicaid-enrolled children determined eligible for HBTS; declining referrals when the child meets criteria may constitute noncompliance and risk denial.
Include transportation only if clinically justified in the Treatment Plan
Transportation included in a Treatment Plan must be clinically justified and related to accomplishing defined, approved treatment objectives; transportation for convenience will not be approved.
Triggers for suspension or termination and required notifications
Services may be suspended or terminated for loss of Medicaid eligibility, use of HBTS in place of other covered services (e.g., CAITS/CFIT/EOS), unsafe home environment, or failure to follow program rules despite documented attempts to remediate; providers must inform referral sources and give 30 days' written notice to families when discontinuing services.
Multiple restraints may trigger emergency consultation and re-evaluation
Multiple restraints on a daily or weekly basis may prompt emergency psychiatric or medical consultation and re-evaluation of continuation of HBTS; this could lead to declining or terminating services.
Complete BCI and CANTS and maintain required licensure/certification
All potential employees must successfully complete Background Criminal Investigation (BCI) and Child Abuse Neglect Tracking System (CANTS) screenings; failure to complete these checks or to maintain required Rhode Island licensure/certification for licensed roles jeopardizes ability to provide HBTS.
Risk of sanctions and recoupment for noncompliance
EOHHS may require recoupment of funds and impose sanctions (provisional approval, rate reductions, suspension of new referrals, revocation) for violations of Certification Standards or Medicaid/State laws.
Medical necessity and potential service limits or exclusions
EOHHS may exclude any item or service determined not medically necessary, unsafe, experimental, or not generally accepted; providers must ensure services billed are medically necessary and supported by documentation.
PA required for many HBTS services and each consultation/coordination
Prior authorization is required for each Pre-Treatment Consultation, Treatment Coordination, Post Treatment Consultation, and for each service within the authorization period; secure PA for each service component.
Program Background and Scope
HBTS is intended for children and adolescents with moderate to severe special health care needs whose care requirements exceed those of typically developing peers and who need services more intensive than outpatient treatment but less restrictive than inpatient or residential care. HBTS includes Specialized Treatment and Treatment Support, is family‑inclusive, requires a physician prescription and an approved Treatment Plan with measurable goals, and is not a replacement for emergency care, psychiatric care, or mandated educational therapies.
Key Terms and Definitions
Level of Care and Placement Criteria
Outpatient (intensive/home-based) — Level of care criteria (HBTS/outpatient) placeholder
Level of care criteria (HBTS/outpatient):
Provider-agency must substantiate treatment intensity and coordination with other services.
Home-Based (HBTS) — Level of care criteria placeholder
Level of care criteria for Home-Based (HBTS):
HBTS is more intensive than outpatient but less restrictive than inpatient; not intended as respite or companionship.
Phased HBTS Levels — criteria grouping for phased HBTS levels
Phased HBTS Levels — phase-based criteria grouping:
Families with recent outpatient services may be exempt from Phase 1 Pre-Treatment.
Home-based (intensive outpatient-like/treatment support) — criteria placeholder
Home-based (intensive outpatient-like/treatment support) — criteria placeholder:
Provider must document rationale for the allocation of Specialized Treatment vs Treatment Support hours.
HBTS (Home-Based) — referenced again as a criteria_group placeholder (high importance)
HBTS (Home-Based) — key criteria and linkage to ABA services:
Additional supports for ABA require authorization from EOHHS or third-party payer.
Applied Behavior Analysis (ABA) Specific Criteria
ABA service criteria
ABA provision and oversight expectations
Additional supervision and Lead Therapy hours for ABA require authorization; BCBA/BCaBA licensure mandated and overseen by RI DOH.
ABA Services/Subsets
ABA-specific service notes:
Lead Therapist responsibilities include supervision documentation, materials prep, observation, and emergency coverage.
ABA program standards
Provider-agency ABA program requirements for children with autism
Appendix 6 lists program requirements and expectations for restrictive procedures, staff training, and use of supervision/lead therapy.
Services, Consultations, and Supervision
HBTS service components
HBTS service components (top-level)
Each modality requires documentation in the Treatment Plan and appropriate clinical supervision.
Therapy consultations
Pre/Post/Treatment Consultation components
Consultation units and personnel qualifications are phase-dependent and prior authorization is required for each service.
Treatment Support
Treatment Support service component details
Rationale for Treatment Support must be clearly articulated and linked to treatment support domains (Appendix 2).
Crisis intervention / Restraint practices
Crisis intervention and restraint practice criteria
Restraint is a last resort; multiple restraints trigger emergency consultation and may lead to declining/terminating services.
Provider-agency policies must address restraint use and monitoring.
BCBA/BCaBA clinical supervision
BCBA/BCaBA clinical supervision requirements and structure
BCBA/BCaBA certified individuals are eligible for licensure and may provide supervision; supervisors must document activities and maintain competence.
ABA / HBTS Specialized Treatment
ABA within HBTS Specialized Treatment details
Appendix 6 specifies program-level requirements and expectations for restrictive procedures and staff training.
ABA / Lead Therapy
Lead Therapy role and requirements
Lead Therapist may observe the assigned child and treatment worker once per month and document supervision activities.
Service Frequency, Intensity, and Workforce Limits
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