CurrentFidelis CarePolicy N/A

Applied Behavioral Analysis Treatment Report

A provider-submitted authorization and clinical documentation form for requesting Applied Behavioral Analysis (ABA) services through Fidelis Care (Medicaid/CHP/Marketplace), including required attachments, diagnostic documentation, functional assessments, treatment schedules, and billable CPT codes. The form outlines required supporting documents for concurrent reviews and billing code guidance.

Policy Summary

PayerFidelis Care

PolicyApplied Behavioral Analysis Treatment Report

Policy CodePolicy N/A

Change TypeInformational / Form guidance

Effective Date

Next Review Date

Key ActionComplete all form fields, attach required documentation, and fax the completed form and supporting documents to 833-561-0094.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes identified in this brief.

10CPT Codes Listed

1Required Concurrent Documentation Set

Policy Overview

This is a provider-submitted authorization and clinical documentation form to request Applied Behavioral Analysis (ABA) services through Fidelis Care covering Medicaid, Child Health Plus (CHP), and Marketplace plans. The form collects member and provider identifiers, treatment dates, requested CPT codes and hours, and requires submission of specified attachments and supporting clinical documentation. Required attachments include diagnostic documentation, functional assessments and re-assessment results, treatment schedules, and the concurrent review packet (weekly progress notes, treatment planning, LBA supervisory documentation, ABC sheets, and signed parent/guardian visit attestations).

Coverage & Documentation Requirements

Diagnosis Documentation Requirement

Must include ALL of the following:

ALL of the following

ICD-10/DSM-V diagnosis (e.g., ASD or Rett Syndrome) documented per DSM-V
Signed documentation by eligible NYS provider: Documentation signed by a NYS Medicaid-enrolled licensed physician, psychologist, psychiatric (or pediatric) nurse practitioner, or physician assistant
Diagnosing practitioner info and date: Diagnosing practitioner name & MMIS # and date diagnosis made
Diagnosis recency: Diagnosis documentation must be within last 24 monthswithin last 24 months

Required Documentation for Concurrent Review

Concurrent reviews must include ALL required documentation below:

ALL of the following

Weekly progress notes and any associated graphs or charts related to goal attainment
Treatment planning documentation
LBA supervisory documentation: Documentation of LBA supervisory sessions
ABC/parent documents: Completed ABC sheets and/or other parent requirement documentation
Signed visit attestations:

Functional Behavior / Skill Acquisition Assessment Requirements

Acceptable assessments for functional behavior or skill acquisition

FBA: Functional Behavior Assessment (FBA)
Traditional Functional Analyses
IISCA: Interview-Informed, Synthesized Contingency Analysis (IISCA)
VB-MAPP for skill acquisition
ABLLS-R

CPT Codes and Billing Categories

Billable/Requested CPT Codes (coverage varies by plan)CPT

97151	Assessment & treatment plan development by QHP; Assessment; Coverage by Plan = Medicaid/CHP/Marketplace
97152	Assessment & treatment plan development by Tech; Assessment; Coverage by Plan = Medicaid/CHP/Marketplace
0362T	Behavior Identification Supporting Assessment; Assessment; Coverage by Plan listed
97153	Adaptive behavior treatment by Tech; Treatment; Coverage by Plan = Medicaid/CHP/Marketplace; For Medicaid: Covered effective 4/1/23
97154	Group (2+) adaptive behavior treatment by Tech, supervised by QHP; Treatment; Coverage by Plan = Medicaid/CHP/Marketplace
97155	Adaptive behavior treatment by QHP; Treatment; Coverage by Plan = Medicaid/CHP/Marketplace
97156	Family adaptive behavior treatment/guidance to caregiver by QHP; Treatment; Coverage by Plan = Medicaid/CHP/Marketplace; For Medicaid: Covered effective 4/1/23
97157	Multiple family group adaptive behavior treatment guidance to sets of caregivers by QHP
97158	Indirect services/direction of Tech by QHP; Group adaptive behavior treatment with protocol modification by QHP; Coverage: Medicaid/CHP/Marketplace; May be bundled when QHP directs without client present
0373T	Listed as equivalent/related to 97158/97155/97153 in form text (Exposure Adaptive Behavioral Treatment/indirect services)

Actionable Provider Requirements

Documentation Required

Complete all form fields and attach required documentation

Complete all fields on the form, attach required supporting documentation, and fax the completed form and attachments to 833-561-0094. Note that blank or incomplete fields are considered incomplete clinical information and can delay or prevent processing of your request.

Fax: 833-561-0094
Incomplete or blank fields may delay or prevent processing

Documentation Required

Diagnosis documentation timeliness

Provide an ICD-10/DSM-V diagnosis (e.g., ASD or Rett Syndrome) documented per DSM-V and signed by an eligible NYS Medicaid-enrolled provider within the last 24 months. Include the diagnosing practitioner's name and MMIS ID and the date the diagnosis was made.

Acceptable diagnosing providers: NYS Medicaid-enrolled licensed physician, psychologist, psychiatric (or pediatric) nurse practitioner, or physician assistant

Documentation Required

Concurrent review required attachments

For concurrent reviews, include all required attachments listed below. Submit these with the concurrent review request to avoid incomplete clinical submission.

Weekly progress notes and any associated graphs or charts related to goal attainment
Treatment planning documentation
Documentation of LBA supervisory sessions
Completed ABC sheets and/or other parent requirement documentation
Signed Visit Attestations from Parent/Guardian

Billing Rule

Billing guidance for indirect/QHP direction services

When a QHP directs a technician without the client present, that indirect/direction service is considered bundled and should not be billed separately. Exposure adaptive behavioral treatment may be reported concurrently with technician-delivered services when the patient is present and protocols are modified; follow the form guidance on bundling and concurrent reporting.

Affected codes: 97158
Affected codes: 0373T
Affected codes: 97153
Affected codes: 97155

Documentation Required

Functional assessment requirement for behavior goals

For goals related to functional behavior, submit one of the required functional assessments (FBA, traditional functional analysis, or IISCA) per Fidelis Care Clinical Policy. Indicate the severity/support level required for problem behavior as MILD, MODERATE, or SEVERE.

Acceptable assessments: Functional Behavior Assessment (FBA); Traditional Functional Analyses; Interview-Informed, Synthesized Contingency Analysis (IISCA)
Indicate severity/support level: MILD / MODERATE / SEVERE

Documentation Required

Re-assessment longitudinal results

Include standardized assessment results over time to document progress. Provide the assessment name, dates, and results (for example VB-MAPP total scores and dates) including current and prior results to show change over time.

Examples to include: VB-MAPP total scores and dates; AFLS; ABLLS-R; VB-MAPP Barriers
Provide current and prior results with dates to demonstrate longitudinal change

OpenPayer

Applied Behavioral Analysis Treatment Report

Policy Overview

Coverage & Documentation Requirements

CPT Codes and Billing Categories

Actionable Provider Requirements

Definitions