Prior authorization procedure for HBTS

Prior authorization (PA) is required for reimbursement of HBTS. For fee-for-service families, each HBTS provider must submit prior authorization requests using the weekly batch PA form once a week, before the service start date; managed care providers must follow their third‑party payer procedures.

• Submit batch PA once weekly for FFS families, prior to service start date.
• Follow third‑party payer PA procedures for managed care enrollees.

Authorization required for additional ABA supports

Additional ABA supports — including extra hours for Clinical Supervision and Lead Therapy associated with discrete trial ABA interventions — require authorization and may only be provided by ABA‑recognized providers with approval from EOHHS or the family’s insurer.

• Authorization required for additional supervision and lead therapy hours for ABA.
• Only ABA‑recognized providers may provide these additional supports with authorization.

PA codes and required reports; treatment plan approval

Prior authorization procedure codes and required reports are specified in the appendices; Treatment Plan approval and the listed PA codes must be obtained prior to delivering services.

• See appendices (including Appendix 15) for PA procedure codes and required reports.
• Treatment Plan approval and applicable prior authorization must be in place before services begin.

Single approved provider‑agency is sole billing agent

EOHHS requires that a single legally incorporated entity be approved as the HBTS provider‑agency and that this certified provider‑agency act as the sole billing agent and accountable entity for all HBTS services.

• Certified HBTS provider‑agency is the single legal entity responsible for performance.
• That approved agency must be the single billing agent for all HBTS.

EOHHS review required for supervisor/consultant >30 hrs/week

Any pattern in which a Clinical Supervisor or Treatment Consultant provides more than 30 hours of service per week, unless approved by EOHHS, will be subject to review by EOHHS.

• Patterns >30 hours/week for a Clinical Supervisor or Treatment Consultant trigger EOHHS review.
• Approval by EOHHS is required to exceed this threshold without review.

Provider application, review time, and Letter of Approval

Applicants for HBTS provider approval undergo EOHHS review (anticipate a minimum of two months) and must receive a Letter of Approval to become certified; EOHHS may place limits on services per Medicaid regulations.

• Expect a minimum ~2 month review process including possible on‑site inspections.
• A Letter of Approval is issued on favorable determination; EOHHS may limit amount, duration, and scope of services.

PA required for T1024 TG/TF and Pre/Post‑Treatment Consultation

Prior authorization is required for Home Based – Specialized Treatment (T1024 TG) and Home Based – Treatment Support (T1024 TF); Pre‑ and Post‑Treatment Consultation also require prior authorization for each 6‑month authorization period.

• T1024 TG and T1024 TF require prior authorization.
• Pre‑ and Post‑Treatment Consultation require PA for each 6‑month authorization period.

Prior authorization — unspecified in these chunks

(No specific prior authorization action stated in the cited segments.)

Step therapy — not specified

(No step therapy requirements are specified in these sections of the policy.)

Coordinate benefits: Medicaid pays after commercial exhaustion

When a child has both commercial insurance and Medicaid, Medicaid will pay only after commercial benefits are exhausted; payment reverts to commercial insurance at the start of each benefit year — providers and families must verify and coordinate benefits.

• Providers/families must verify commercial coverage and provide proof to EOHHS.
• Medicaid assumes payment after commercial benefits are exhausted; payment reverts at each benefit year start.

HBTS only when intensified outpatient care insufficient; not with CAITS/CFIT/EOS

HBTS should be considered when intensified outpatient services have been insufficient; HBTS is not intended when CAITS, CFIT, or EOS are being used.

• Ensure intensified outpatient services have been insufficient before initiating HBTS.
• Do not provide HBTS when CAITS, CFIT, or EOS are in use.

Use restraint only as last resort with required training and documentation

Physical restraint is permitted only as a last‑resort emergency intervention presenting an immediate and serious safety risk; staff must follow documented protocols, be certified in crisis intervention and restraint techniques, and each episode must be documented and reviewed by the Clinical Supervisor.

• Restraint permitted only for immediate, serious safety risks and as last resort.
• Staff must be certified in crisis intervention and restraint techniques and First Aid/CPR.
• Each restraint episode must be documented and reviewed by the Clinical Supervisor.

Initiate HBTS referrals with Phase 1 Pre‑Treatment (2 hrs/week)

All HBTS referrals begin with Phase 1 Pre‑Treatment (up to 6 months) unless the family received outpatient services addressing the same issues in the past 6 months; Pre‑Treatment intensity is 2 hours/week by a licensed clinician.

• Phase 1 Pre‑Treatment is up to 6 months; families with relevant outpatient services in past 6 months may be exempt.
• Pre‑Treatment intensity: maximum 2 hours/week (4 units/week, 30‑minute units) by a licensed clinician.
• Prior authorization is required for each 6‑month authorization period.

Phase‑based initiation: start with Pre‑Treatment unless exempt

Families generally must begin with Phase 1 Pre‑Treatment (up to 6 months) unless exempt due to recent outpatient services; providers may continue Pre‑Treatment another 6 months if family will not proceed to Phase 2.

• Exemptions: families who received relevant outpatient services within past 6 months.
• Pre‑Treatment may be extended another 6 months if needed; outpatient referral recommended for longer‑term care.

Obtain physician prescription and maintain signed Treatment Plan with measurable goals

Provider‑agencies must obtain a physician's prescription documenting medical necessity and maintain an approved, signed Treatment Plan with defined, measurable goals and objectives; Treatment Plans must be reviewed at major decision points and at least every six months.

• Physician's prescription required as the basis for HBTS services.
• Treatment Plan must be current, comprehensive, individualized, signed by a licensed practitioner, contain measurable goals, and be reviewed at admission/discharge/major change and at least every 6 months.

Substantiate and document treatment intensity; observe 20‑hour (non‑ABA) limit

Treatment intensity (hours/week) must be justified in the record with documented medical necessity and measurable goals; non‑ABA HBTS is limited to up to 20 hours per week (combined HBTS+PASS up to 25 hrs with collaboration) and provider‑agency must justify the number of hours in the Treatment Plan.

• Document medical necessity and measurable goals tying to frequency and duration for requested hours.
• Non‑ABA HBTS: up to 20 hours/week; combined HBTS+PASS: up to 25 hours/week when documented and collaborated.
• Provider‑agency is responsible to justify hours as medically necessary.

Document measurable goals, use collateral info, and obtain caregiver signatures

Provider‑agencies must document written, specific, measurable treatment goals and objectives tied to intervention methods and measurement of progress; use collateral information (IEP/IFSP, evaluations) and obtain parent/caregiver signatures on Treatment Plans.

• Include specific, measurable goals, defined interventions, and methods for measuring progress in the Treatment Plan.
• Utilize referral/collateral information (IEP/IFSP, provider contacts, evaluations).
• Parents/Caregivers/Guardians must sign proposed Treatment Plans.

Ensure diagnosis within 3 years and include required evaluations for initial/continuing care

Initial Treatment Plan approval requires a formal behavioral health or medical diagnosis made within 3 years, a clinical diagnostic interview, evidence of functional impairment, and any necessary neuropsychological/educational/language evaluations; continuing care requires measurable progress documentation.

• Diagnosis must be within 3 years and supported by clinical interview and evidence of impairment.
• Include necessary testing/evaluations (neuropsychological, psychological, educational, language) as appropriate.
• Continuing authorization requires documentation of measurable progress toward goals.

Document reasons and provide 30‑day notice for suspension/termination

When suspending or terminating HBTS, document specific reasons, provide written notice to parents/caregivers and referral source/medical home 30 days prior, and maintain continuous written documentation describing safety concerns that led to suspension/termination.

• Provide 30 days' written notification to family, referral source, and medical home prior to discontinuation.
• Document specific reasons and maintain continuous written safety documentation leading to suspension/termination.
• Inform families of dispute resolution procedures and provide transitional support.

Support all billing with comprehensive client records

All billed services must be substantiated in the client record; client records must include initial and detailed assessments, Treatment Plan, documentation of services provided, changes in status, progress notes, and evidence of informed consent where required.

• Client record must support all billed service hours; records form the basis for billing.
• Include assessments, Treatment Plan, service documentation, progress notes, and discharge summaries when applicable.
• Entries must be dated, authenticated, and reflect reasons for clinical judgments.

Document clinical supervision with specified elements

Clinical supervision documentation must include the child’s name; recipient(s) of supervision; date; place; duration; purpose and content; recommendations and follow‑up; and signature of the Clinical Supervisor.

• Document date, place, duration, recipient(s), purpose/content, recommendations/follow‑up, and supervisor signature for each supervision event.

Document and clinically review every restraint episode

Each restraint episode must be documented and reviewed by the Clinical Supervisor for necessity and alternative interventions; Clinical Supervisor must document dates, duration, which worker received supervision, and sufficient content to substantiate service delivery.

• Document each restraint episode in detail and have Clinical Supervisor review for necessity and alternatives.
• Clinical Supervisor documentation must include date, duration, recipient of supervision, and sufficient content.

Maintain Treatment Plans and records available for EOHHS inspection

Providers must maintain comprehensive Treatment Plans documenting medical necessity signed by a licensed practitioner; records, claims documentation, clinical supervision notes, and related documentation must be available for EOHHS inspection, including site visits.

• Treatment Plans must be signed by a Licensed Practitioner of the Healing Arts.
• Maintain records and documentation accessible for EOHHS site visits and inspections; repayment or self‑audit may be required for adverse findings.

Document consultations, supervision, and data collection

Consultations, supervision, and treatment activities (including data collection on goals/objectives) must be documented; home‑based workers must collect and manage shift data and Clinical Supervisors must document supervision.

• Document consultations, supervision, and data collection on treatment goals/objectives.
• Home‑based workers collect data during shifts for targeted behaviors; clinical supervisors document supervision and summary reports.

Collect shift data and prepare summary reports

Home‑based workers must collect and manage data during shifts for targeted behaviors and prepare summary reports; clinical supervisors must document supervision activities and data for reports.

• Collect direct observation data on target skills and challenging behaviors during shifts.
• Prepare summary reports; Clinical Supervisors document supervision and compile data for reporting.

Maintain complaint logs and family satisfaction records for review

Maintain complaint logs with timeliness of complaint resolution and annual family satisfaction summaries; provide these records upon EOHHS request.

• Keep complaint logs and document timeliness of complaint resolution.
• Conduct and summarize annual family satisfaction surveys and provide results upon request.

Prior authorization required for reimbursement

Reimbursement for HBTS requires prior authorization (PA); failure to obtain required PA may result in denial of reimbursement.

• Obtain PA prior to billing to avoid denial of reimbursement.

Avoid preferential enrollment — risk of certification suspension/termination

A material breach such as preferential enrollment based on referral source or third‑party payer may be grounds for suspension or termination of certification; providers must not preferentially enroll clients.

• Do not preferentially enroll families based on referral source or payer; such conduct may be considered a material breach and trigger suspension/termination.

Do not use HBTS as respite/childcare or for experimental treatments

Using HBTS as respite, childcare, or for experimental treatments is not medically necessary and can lead to denial of services and reimbursement.

• Do not bill HBTS for respite, childcare, or experimental treatments; these uses are non‑covered and may be denied.

Verify continuous Medicaid eligibility to avoid non‑payment

Provider‑agencies must verify continuous Medicaid eligibility; failure to verify coverage can result in non‑payment or denial.

• Confirm and document continuous Medicaid enrollment before providing and billing services.

Providers may decline referrals with restraint history; multiple restraints trigger re‑evaluation

Provider‑agencies may decline referrals when there is a history or high likelihood of restraints; multiple restraints on a daily or weekly basis may trigger emergency psychiatric/medical consultation and re‑evaluation of HBTS continuation.

• Providers may decline referrals with prior restraint history or high likelihood of restraints.
• Multiple restraints may prompt emergency consultation and re‑evaluation of continued HBTS.

Repeated restraints may trigger emergency consultation and continuation review

Multiple restraints occurring daily or weekly may trigger emergency psychiatric/medical consultation and re‑evaluation of continued HBTS; providers must monitor and document restraint frequency.

• Document frequency of restraints; repeated incidents require emergency consultation and program re‑evaluation.

EOHHS may limit or exclude services deemed not medically necessary

EOHHS may exclude or limit services it determines are not medically necessary, unsafe, experimental, or not generally accepted; providers should expect EOHHS to set amount, duration, and scope limits.

• EOHHS can limit or exclude services based on medical necessity and safety considerations.
• Providers should comply with EOHHS determinations on amount, duration, and scope.

Adverse site‑visit findings can trigger repayment or self‑audit

Adverse findings on EOHHS site visits may require repayment; significant irregularities in billing or utilization may trigger a complete self‑audit and repayments.

• Maintain accurate claims and documentation to avoid repayment or required self‑audit.
• EOHHS site visits review client records, claims documentation, supervision notes, time sheets, and other materials.

PA required for T1024 TG and T1024 TF (and Pre/Post consultations)

Prior authorization is required specifically for T1024 TG (Home Based – Specialized Treatment) and T1024 TF (Home Based – Treatment Support); Pre‑ and Post‑Treatment Consultations also require PA for each authorization period.

• Obtain PA for procedure codes T1024 TG and T1024 TF before delivering/billing those services.
• Secure PA for Pre‑ and Post‑Treatment Consultation for each 6‑month authorization period.

Service delivery performance is measured; failure to deliver may trigger oversight

Failure to deliver authorized direct service hours may be measured and reported (performance metrics) and high percentages of undelivered services for provider reasons may trigger oversight actions.

• Measure % of delivered authorized direct service hours; monitor provider‑ and family‑caused non‑delivery.
• High rates of services not delivered may lead to EOHHS oversight or corrective action.