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.
No material clinical or coverage changes identified in this brief.
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).
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