ModifiedFidelis CarePolicy FC.CP.BH.301.04

Applied Behavior Analysis (ABA) services

Defines medical necessity, documentation, assessment, treatment planning, continuation, and exclusion criteria for coverage of Applied Behavior Analysis (ABA) services for members with autism spectrum disorder (ASD) under Fidelis Care in North Carolina.

Policy Summary

PayerFidelis Care

PolicyApplied Behavior Analysis (ABA) services

Policy CodePolicy FC.CP.BH.301.04

Change TypeMaterial updates to diagnostic currency, intensity ranges, and school-based coverage

Effective Date

Next Review Date

Key ActionObtain and submit a current Comprehensive Diagnostic Evaluation (within 5 years) or qualified clinician confirmation letter to initiate prior authorization.

SourceLink

POLICY UPDATE CHANGES

Updated description to include definition of focused and comprehensive ABA treatment and changed intensity range for Comprehensive ABA from 25-40 to 30-40 hours per week.

Added requirement that a Comprehensive Diagnostic Evaluation (CDE) must be completed within 5 years for confirmation of ASD diagnosis; a letter of confirmation from a qualified health professional may be accepted to begin services if CDE cannot be obtained within 6 months.

Added language that services provided in school will not be covered by the plan; a transition period is allowed.

Added requirement for established and current (within 24 months) DSM-5 diagnosis and required evidence-based assessments; progress updates required every 3 months.

30-40 hrs/wkComprehensive ABA intensity

10-25 hrs/wkFocused ABA range

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Coverage and Medical Necessity Criteria

inv-01: Initial Therapy

Covered when ALL of the following are met

Initial ABA coverage: A comprehensive diagnostic evaluation within the past 5 years that documents functional impact across settings (communication, socialization, restricted/repetitive behaviors, adaptive functioning); a confirmed ASD diagnosis by a NYS-licensed qualified clinician per DSM-5 or state-defined criteria; diagnosis confirmation by an approved screening/diagnostic tool; a recommendation or referral for ABA within the last 2 years; and the requested services meet the assessment or initiation criteria in section I.E.

See I.E for acceptable screening tools and required assessment elements.

inv-02: Assessment and Initiation Criteria

For requested services to be covered, ONE of the following service categories must be documented and meet listed elements

Behavioral assessment completed by a Board-Certified Behavior Analyst (BCBA) or equivalent provider including: record review; interviews; rating scales; and direct observation; and one or more of the following as indicated: functional behavioral assessment (descriptive FBA, traditional functional analyses, or IISCA) for disruptive/dangerous behaviors, or a skills acquisition assessment (e.g., VBMAPP, ABLLS-R, AFLS, PEAK, SSIS, EFL, Socially Savvy, or other evidence-based tools).

Acceptable FBA and skills assessment types listed in I.E.1.b.

Initiation of ABA treatment: An ABA assessment as above plus an individualized treatment plan aligned with assessment results that includes measurable goals and timelines (including transition/discharge planning), justification of requested hours based on impairment and response to intervention, supervision and caregiver training plans, coordination of care, focus on core symptoms and generalization, and documentation that treatment will be delivered or supervised by ABA-credentialed professionals.

Supervision standard: 1-2 hours supervision per 10 hours direct treatment; 2 hours recommended if <10 direct hours/week.

inv-03: Continuation Therapy

Coverage continues when ALL of the following are met

Continuation of ABA: Initial authorization criteria remain met; assessments and documentation are current and completed at least every six months during ABA treatment; discharge criteria have been reviewed and adjusted as appropriate; the member's behavior is not exacerbated by treatment; and there is a reasonable expectation of benefit demonstrated by either documented progress toward goals within six months or, if progress is limited, an updated assessment identifying barriers plus specific treatment plan modifications addressing those barriers and alternative supports.6 months

Updated treatment plan and progress data required every 6 months; CDE required every 5 years.

inv-04: Discharge/Transfer

Services may be discontinued or transferred when ALL of the following transition/discharge conditions are addressed

Discharge/Transition: Transition planning with input from the entire care team; clearly defined and measurable discharge criteria; and presence of one or more of the following: no longer meeting continued-stay criteria or meeting criteria for another level of care; treatment goals met; caregiver able to continue interventions independently; withdrawal of consent; expected transition to community or school resources; or no clinically significant progress for at least 6 months with low expectation that revision will lead to improvement.6 months

Includes list of acceptable reasons for discharge or transfer as described in II.C.

inv-05: Initial and ongoing coverage requirements

Covered when ALL of the following are met:

Diagnostic confirmation: An established and current DSM-5 diagnosis of ASD within the past 24 months and a Comprehensive Diagnostic Evaluation (CDE) confirming ASD; the CDE must be current within 5 years. If a CDE cannot be obtained within 6 months of the request for services, a letter of confirmation from a qualified health professional may be accepted to begin services.CDE within 5 years; DSM-5 within 24 months

Qualified clinicians and provisional acceptance criteria described in policy and provider manual.

Assessment documentation: Standardized psychological assessment documenting interviews (child, parent/guardian, teachers), educational and behavioral history, observation of core ASD symptoms, differential diagnosis, and specification of severity, course specifiers, intellectual and language status, and relevant medical/genetic factors.

Evaluations should be updated periodically; policy references best practice of updating every three years and requires evidence-based assessments.

Treatment plan and intensity:

Services that are otherwise provided under the Individuals with Disabilities Education Act (IDEA) are excluded from Fidelis Care coverage. In addition, beginning 9/1/23 Fidelis Care will not cover ABA services provided in a school setting in New York State because those services and supports are the responsibility of the member’s school district; coordination with school services and transition plans is permitted but school-delivered services are excluded.

Services delivered in school settings are not covered by the plan; the policy includes language allowing a short transition period for members who previously received school-hour services. Providers and care teams should plan for an orderly transition of services to meet the member’s healthcare needs during that permitted transition interval.

Coverage of ABA services is subject to the exclusions, limitations, terms and conditions of the member’s coverage documents (for example, Evidence of Coverage, Certificate of Coverage, policy or contract) and to applicable state and federal requirements and Health Plan administrative policies and procedures. Providers should verify applicable benefit and prior authorization requirements in the member’s coverage documents before rendering services.

ABA services will not be covered when the requested goals are more appropriately addressed by other disciplines or systems. Examples include goals that are the responsibility of the school district or that are better met through behavioral health outpatient services, speech therapy, occupational therapy, vocational rehabilitation, supportive respite care, recreational therapy, or orientation and mobility.

The policy was revised to remove prior language that explicitly required ruling out certain conditions (for example, neurological disorder, lead poisoning, or primary speech/hearing disorder) as part of diagnostic criteria. The revision notes state that those rule-out statements were removed because they are implied and therefore no longer explicitly required.

Policy Identifiers and Code Lists

Policy identifiermixed

FC.CP.BH.301.04

Fidelis Care policy reference number (document identifier)

Referenced CPT/HCPCS Codesmixed

97151	Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes
97152	Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes
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, each 15 minutes
97156	Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional, face-to-face with guardian(s), each 15 minutes
97157	Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional, face-to-face with multiple sets of guardians, 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; requires physician/QHP on site and two or more technicians, for a patient with destructive behavior
0373T	Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient; requires physician/QHP on site and two or more technicians, for a patient with destructive behavior

ICD-10-CM Codes referencedICD-10

F84.0	Autistic disorder
F84.2	Rett's syndrome
F84.3	Other childhood disintegrative disorder

ABA intensity

Focused ABA intensity10-25 hours per week (direct treatment)

Comprehensive ABA intensity30-40 hours per week (direct treatment) plus direct and indirect supervision and caregiver training

Intensity individualizationIntensity must be individualized to the person's characteristics, needs, age, school attendance, and daily activities

Prior Authorization, Documentation, and Administrative Actions

Prior Authorization

Prior Authorization, Coverage Verification

Prior Authorization Required: Prior authorization is required for initiation and continuation of ABA services. Coverage is subject to the member's plan terms, conditions, exclusions, and limitations; verify prior authorization and coverage under the applicable evidence of coverage/certificate of coverage/policy and any Health Plan-level administrative policies prior to scheduling services.

Prior authorization must accompany requests for initiation of ABA treatment and for ongoing authorizations.
Referral from a provider must be within 2 years of the request for services as outlined in the ABA provider manual.

Prior Authorization

Prior Authorization Requirements for ABA Services

Prior authorization documentation for ABA services must demonstrate an established DSM-5 diagnosis of ASD and evidence-based assessment findings supporting medical necessity. For ABA service requests, an established and current DSM-5 diagnosis within 24 months is required unless a comprehensive diagnostic evaluation (CDE) is available per policy.

DSM-5 diagnosis must be documented and current within 24 months of the request unless overridden by a valid CDE.

Clinical Background and Evidence

Applied Behavior Analysis (ABA) is an evidence-based behavioral treatment for autism spectrum disorder that uses systematic assessment, direct observation, measurement, and functional analysis to increase adaptive skills and decrease challenging behaviors. ABA includes formal behavioral assessments (including Functional Behavioral Assessment types such as descriptive FBA, traditional functional analysis, or IISCA), ongoing direct observation and measurement of target behaviors, individualized treatment planning with measurable goals, caregiver training and supervision, and intensity levels that may be focused (10–25 hrs/week) or comprehensive (30–40 hrs/week) depending on the member’s needs.

Key Definitions

Focused ABA

DefinitionDirect care provided to the member/enrollee for a limited number of behavioral targets; appropriate when treatment is needed for a limited set of skills or when acute problem behavior is the priority

Typical age/cognitive scopeNot restricted by age, cognitive level, or co-occurring conditions

Usual weekly hoursTypically 10-25 hours per week of direct treatment

Comprehensive ABA

DefinitionTreatment addressing multiple affected developmental domains (cognitive, communicative, social, emotional, adaptive) and maladaptive behaviors

Common targetsIncludes skills across domains and reduction of maladaptive behaviors such as noncompliance, tantrums, and stereotypy

Service Intensity and Level-of-Care

Clinical Criteria and Evidence Base for ABA

inv-38: ABA Medical Necessity

ABA medical necessity criteria

ABA medical necessity: (A) A Comprehensive Diagnostic Evaluation within 5 years demonstrating functional impairment; (B) confirmed ASD diagnosis by an appropriate licensed clinician; (C) diagnosis confirmation by an approved screening/diagnostic tool; (D) recommendation for ABA within the last 2 years; and (E) the requested service meets behavioral assessment or initiation criteria in section I.E.CDE within 5 years

Includes list of acceptable screening/diagnostic tools and required assessment elements.

inv-39: ABA clinical criteria

ABA treatment focuses and intensity:

Scope of treatment: Targets multiple developmental domains (cognitive, communicative, social, emotional, adaptive) and maladaptive behaviors such as noncompliance, tantrums, and stereotypy.

Service Modalities and Settings

inv-41: ABA (various settings and telehealth)

Modalities: Services may be provided in various settings (home, clinic, school, community) and modalities including in-person and telehealth as appropriate.

inv-42: Applied Behavior Analysis (focused and comprehensive)

Comprehensive vs Focused: Policy differentiates focused and comprehensive ABA: focused targets limited behavioral domains (typically 10-25 hrs/week) while comprehensive addresses multiple developmental domains with higher intensity (commonly 30-40 hrs/week) and includes caregiver training and supervision, individualized to the member's needs.Focused 10-25 hrs/week; Comprehensive 30-40 hrs/week

Caregiver training is performance based and parent-driven; supervision standards described in policy.

Visit Limits and Service Hours

Direct ABA therapy (focused or comprehensive intensity ranges)

Allowed range (focused to comprehensive)10-40 hours per week (combined policy ranges for focused and comprehensive direct ABA therapy)

Policy noteFocused ABA typically 10-25 hrs/week; Comprehensive ABA typically 30-40 hrs/week (plus supervision and caregiver training)

DeterminationIntensity selection must be justified by behavioral assessment, severity, treatment history, and response to intervention

Direct ABA service hours

Determination of hoursNumber and intensity of direct ABA service hours must be justified in the individualized treatment plan based on assessment results, severity, treatment history, and response to intervention

Example intensity

Policy Summary

PayerFidelis Care

PolicyApplied Behavior Analysis (ABA) services

Policy CodePolicy FC.CP.BH.301.04

Change TypeMaterial updates to diagnostic currency, intensity ranges, and school-based coverage

Effective Date

Next Review Date

Key ActionObtain and submit a current Comprehensive Diagnostic Evaluation (within 5 years) or qualified clinician confirmation letter to initiate prior authorization.

SourceLink

On This Page

Documentation Required

Required Diagnostic and Authorization Documentation

Required Documentation for Authorization: Provide a comprehensive diagnostic evaluation (CDE) and ABA-specific assessment documentation when requesting authorization. The CDE must have been completed within the past five years and include sufficient detail to confirm ASD diagnosis and document functional impact across settings.

Comprehensive Diagnostic Evaluation (CDE) completed within 5 years that includes: standardized psychological assessment, interviews with child/family/teachers, educational history, behavioral interventions, family history, observation of core ASD symptoms, severity rating, specifiers (intellectual impairment, language impairment, catatonia), and any relevant medical/genetic factors.
If a current CDE is not available, a provisional letter of confirmation from an appropriate licensed clinician (e.g., NYS-licensed physician, psychologist, psychiatric nurse practitioner) is acceptable to initiate services while CDE is obtained within 6 months.
DSM-5 diagnostic details including severity level must be included and corroborated by standardized screening/assessment tools as listed in policy.

Documentation Required

Behavioral Assessment Requirements

Required ABA assessment documentation must be completed by a Board-Certified Behavior Analyst (BCBA) or equivalent provider prior to requesting treatment services and must include a record review, interviews, rating scales, and direct observation. The assessment must support the requested level of service and treatment hours.

ABA/behavioral assessment components: record review; interviews; validated rating scales; direct observation.
Assessment types: Functional Behavioral Assessment (Descriptive FBA, Traditional functional analyses, IISCA) for problem behaviors; Skill acquisition assessments (VB-MAPP, ABLLS‑R, AFLS, PEAK, SSIS, EFL, Socially Savvy, or other valid evidence‑based tools) as appropriate.
Assessment must justify number of service hours requested, supervision needs, and caregiver training requirements.

Documentation Required

Treatment Plan, Progress, and Reauthorization

Treatment Plan and Ongoing Authorization Requirements: The individualized treatment plan must align with assessment results, contain measurable goals, timelines (including transition/discharge planning), caregiver training, and justify requested hours. Updated treatment plans and progress documentation are required at specified intervals for continuation.

Initial treatment plan must be strengths-specific, family-focused, community‑based, culturally competent, least intrusive, and include measurable goals and timelines.
Requested hours must be justified by impairment level, symptom severity, treatment history, response to intervention, and consider age, school attendance, and daily activities.
Updated treatment plan and progress documentation required every 3 months for some plans and every 6 months for treatment-plan updates per policy; continuation requires documented progress toward goals or documented barriers and a revised plan addressing those barriers.

Denial Risk

Excluded Services and School-Based Noncoverage

Excluded Services and School-Based Noncoverage: ABA services will not be covered when services are otherwise covered under IDEA or when treatment goals are more appropriately provided by other disciplines. ABA services delivered in school settings are not covered by the plan (Fidelis Care) as of specified effective date; a 30‑day transition period is allowed for members already receiving school-hour services.

Not covered: services covered under IDEA.
Not covered: goals more appropriately provided by behavioral health outpatient services, speech therapy, occupational therapy, vocational rehabilitation, supportive respite care, recreational therapy, orientation and mobility.
School-based services: ABA delivered in a school setting will not be covered beginning 9/1/23; members previously receiving services during school hours are allowed a 30-day transition period.

Note

Coverage Documentation and Regulatory Precedence

Coverage Documentation and Plan-Level Precedence: All coverage determinations are subject to the member's evidence of coverage and plan documents. Confirm authorizations, limits, exclusions, and any state or federal program-specific requirements prior to providing services.

Coverage is governed by the member's plan documents (EOC, policy, certificate of coverage) and Health Plan administrative policies.
For Medicaid members, state Medicaid coverage provisions take precedence over this clinical policy where conflicts exist — consult the state Medicaid manual.
For Medicare members, review applicable NCDs/LCDs/Coverage Articles prior to applying policy criteria.

Prior Authorization

Provider Administrative Actions

Provider Action Reminder: Providers must verify prior authorization status, ensure all required diagnostic and assessment documentation is submitted with the authorization request, and confirm that requested services do not duplicate school-provided services or services more appropriately provided by other disciplines.

Ensure referrals are within required timeframes and include necessary CDE or provisional diagnostic confirmation.
Submit ABA assessment, treatment plan, and supporting documentation (progress notes, reassessments) with authorization requests.
Do not bill the plan for services provided in a school setting when excluded; coordinate transition arrangements for members affected by the school-based noncoverage rule.

Comprehensive Diagnostic Evaluation (CDE)

DefinitionA diagnostic assessment performed by qualified clinicians (e.g., child developmental-behavioral or neurodevelopmental neurologist, child psychologist, or general neurologist) including standardized assessments to confirm ASD and inform treatment

Recommended update cadenceBest practice recommends updating testing every three years; policy requires CDE currency within 5 years for authorization

ComponentsShould include standardized psychological assessment, interviews (child, parent, teachers), educational and behavioral history, and observation of core ASD symptoms

EIBI / Early Intensive Behavioral Intervention

DefinitionEarly Intensive Behavioral Intervention (EIBI) refers to comprehensive, intensive behavioral interventions for young children with ASD based on established models (e.g., UCLA Young Autism Project)

Relation to ABAEIBI is the application of comprehensive ABA approaches for young children to improve cognitive, language, and adaptive outcomes

Evidence baseSupported by systematic reviews and meta-analyses cited in the policy (e.g., Reichow et al., Campbell Systematic Review, Cochrane Review)

inv-40: Evidence references for ABA

Selected evidence sources cited that support ABA and early intensive behavioral interventions for ASD

Key evidence categories: Systematic reviews, meta-analyses, randomized trials, and practice parameters supporting ABA/EIBI for ASD are cited (e.g., Campbell Systematic Review 2014; Cochrane Review 2018; multiple meta-analyses and practice parameters).

See cited references in policy (chunks 37-39).