Modifiedharvard pilgrim health carePolicy N/A

Applied Behavioral Analysis (ABA) therapy coverage criteria

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Policy governing prior authorization and coverage criteria for Applied Behavioral Analysis (ABA) services for members with Autism Spectrum Disorder (ASD) and Down syndrome for applicable commercial and certain public plans in Massachusetts and participating Tufts/Harvard Pilgrim products.

Policy Summary

Payerharvard pilgrim health care

PolicyApplied Behavioral Analysis (ABA) therapy coverage criteria

Policy CodePolicy N/A

Change TypeMaterial coverage updates (Massachusetts Down syndrome coverage) + code removals

Effective DateJan 1, 2026

Last ReviewJun 18, 2025

Next Review Date

Key ActionObtain prior authorization using the specified InterQual SmartSheets and submit completed documentation via HPHConnect Clinical Upload or secure fax (800-232-0816).

SourceLink

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Modifiedharvard pilgrim health carePolicy N/A

Applied Behavioral Analysis (ABA) therapy coverage criteria

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Sign up for all harvard pilgrim health care policy alerts

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Policy Summary

Payerharvard pilgrim health care

PolicyApplied Behavioral Analysis (ABA) therapy coverage criteria

Policy CodePolicy N/A

Change TypeMaterial coverage updates (Massachusetts Down syndrome coverage) + code removals

Effective DateJan 1, 2026

Last ReviewJun 18, 2025

Next Review Date

Key ActionObtain prior authorization using the specified InterQual SmartSheets and submit completed documentation via HPHConnect Clinical Upload or secure fax (800-232-0816).

SourceLink

POLICY UPDATE CHANGES

Addition of Coverage for ABA for Down Syndrome in accordance with Mass. General Laws c.176G § 4V-1/2 | Mass.gov effective 1/1/26.

H0031 and H0032 removed from list of applicable codes for HPHC Commercial.

Administrative updates effective January 1, 2026.

RequiredInterQual SmartSheets

5 ASD + 4 DSCovered diagnoses

7Codes needing PA

Aug 20, 2025Last substantive change

Coverage Criteria for ABA Services

General coverage criteria

Covered when ALL of the following are met

Eligibility and medical necessity: Member has a definitive diagnosis of an Autism Spectrum Disorder (one of the listed F84.* ICD-10 codes) OR, for Massachusetts products, Down syndrome (one of the listed Q90.* ICD-10 codes), AND Applied Behavioral Analysis (ABA) is medically necessary for the member and the ABA benefit is included in the member's plan.

Uses InterQual SmartSheets for medical necessity and prior authorization; parents/legal guardians involvement is essential and should be documented.

The policy excludes services that are primarily educational in nature, as well as services provided by school personnel under an Individualized Education Program (IEP), from coverage for Applied Behavioral Analysis (ABA). It also excludes treatments considered investigational or unproven (for example, facilitated communication, Auditory Integration Therapy (AIT), Holding Therapy, and Higashi/Daily Life Therapy) and non-clinical services such as personal training or life coaching.

Administrative update: effective following MPAC review on August 20, 2025, H0031 and H0032 were removed from the list of applicable codes for Harvard Pilgrim Health Care (HPHC) Commercial products. This change is documented in the policy Approval and Revision History.

The policy specifies that ABA therapy is not medically necessary for: (1) services that are primarily educational in nature; (2) services provided by school personnel pursuant to an IEP (these are not subject to reimbursement); (3) investigational or unproven treatments, including but not limited to facilitated communication, Auditory Integration Therapy (AIT), Holding Therapy, and Higashi (Daily Life Therapy); and (4) personal training or life coaching.

Diagnosis and Procedure Codes

Covered ICD-10 Codes (ASD)ICD-10Covered

F84.0	Autistic disorder
F84.3	Other childhood disintegrative disorder
F84.5	Asperger's syndrome
F84.8	Other pervasive developmental disorders
F84.9	Pervasive developmental disorder, unspecified

Covered ICD-10 Codes (Down syndrome) — Massachusetts onlyICD-10Covered

Q90.0	Trisomy 21, nonmosaicism (meiotic nondisjunction)
Q90.1	Trisomy 21, mosaicism (mitotic nondisjunction)
Q90.2	Trisomy 21, translocation
Q90.9	Down syndrome, unspecified

CPT/HCPCS Codes requiring prior authorizationmixed

97151	Behavior identification assessment, each 15 minutes
97152	Behavior identification-supporting assessment, technician, each 15 minutes
97153	Adaptive behavior treatment by protocol, technician, each 15 minutes
97154	Group adaptive behavior treatment by protocol, technician, each 15 minutes
97155	Adaptive behavior treatment with protocol modification, professional, each 15 minutes
97156	Family adaptive behavior treatment guidance, each 15 minutes
97157	Multiple-family group adaptive behavior treatment guidance, each 15 minutes
97158	Group adaptive behavior treatment with protocol modification, each 15 minutes
0362T	Behavior identification supporting assessment, each 15 minutes of technician time face-to-face
0373T	Adaptive behavior treatment with protocol modification, each 15 minutes of technician time face-to-face with required components

1–10 of 11

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Codes requiring prior authorizationCPT | HCPCSCovered

97151	Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan.
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, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes.
97156	Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes.
97157	Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes.
H0031	Mental health assessment, by non-physician

inv-09: Time unit for ABA billing

Time unit for billing15 minutes per unit

Applies to codes97151, 97153-97157, H0031 (and other listed ABA CPT/HCPCS codes)

Billing granularityReport units in 15-minute increments consistent with CPT/HCPCS definitions

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed ABA and related assessment codes. Claims for these services may be denied or payment delayed if prior authorization is not obtained before services are rendered.

Prior authorization required for codes: 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, H0031
Use the appropriate InterQual® SmartSheet(s) when requesting authorization

Documentation Required

Submission of Clinical Documentation

Submit required clinical documentation to support medical necessity determinations. Clinical notes and documentation may be required to complete the authorization review.

Clinical documentation (e.g., assessment reports, treatment plans, progress notes) via HPHConnect Clinical Upload

Background on Applied Behavior Analysis (ABA)

Applied Behavioral Analysis (ABA) is described in the policy as a behavioral treatment approach focused on observation, measurement and modification of environment–behavior relationships; parent/legal guardian involvement and training are considered essential. The policy frames ABA coverage for members with a definitive diagnosis (for example, Autism Spectrum Disorder and, for Massachusetts products, Down syndrome) and relies on InterQual SmartSheets for medical necessity determination and prior authorization. Background and revision history note statutory-driven changes and MPAC review actions that expanded coverage scope (e.g., addition of Down syndrome coverage effective 1/1/26) as well as subsequent administrative updates.

Definitions and Code Descriptions

inv-19: Applied Behavioral Analysis (ABA) — definition and key elements

DefinitionApplied Behavioral Analysis (ABA) includes the design, implementation and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior.

Core elementsDirect observation, measurement, and functional analysis of the relationship between environment and behavior.

Family involvementInvolvement by parents/legal guardians is considered essential; parents/legal guardians are taught to continue behavioral modification training.

ScopeCovered for members with a definitive diagnosis of ASD and/or Down syndrome (for applicable MA plans) when medically necessary and benefit is included in the plan.

inv-20: 97151 — behavior identification assessment description per 15 minutes

Code

InterQual-based ABA Service Subsets

InterQual-based ABA service subsets

InterQual SmartSheets required for specific ABA activities

Required InterQual SmartSheets: Use the InterQual subsets/SmartSheets for the following ABA activities: ABA Assessment; Consultation with other providers/agencies/school personnel; Parent or Caregiver Training; Supervision; and Treatment.

Completed SmartSheets must be submitted with the prior authorization request via HPHConnect or the indicated prior authorization form (Massachusetts Standard Form for MA commercial/direct; Autism Spectrum Disorder Services Prior Authorization Request Form for other states).

ABA Treatment Modalities and Services

ABA (assessment, treatment, caregiver training, supervision)

Procedure-level authorization: Specific CPT/HCPCS procedure codes for ABA (e.g., 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T) and related assessment codes require prior authorization and use of the appropriate InterQual SmartSheet(s).

Applies to Harvard Pilgrim and Tufts commercial products as indicated; time unit = 15 minutes per service unit.

Policy Summary

Payerharvard pilgrim health care

PolicyApplied Behavioral Analysis (ABA) therapy coverage criteria

Policy CodePolicy N/A

Change TypeMaterial coverage updates (Massachusetts Down syndrome coverage) + code removals

Effective DateJan 1, 2026

Last ReviewJun 18, 2025

Next Review Date

Key ActionObtain prior authorization using the specified InterQual SmartSheets and submit completed documentation via HPHConnect Clinical Upload or secure fax (800-232-0816).

SourceLink

On This Page

Alternatively, secure fax to 800-232-0816

Documentation Required

Documentation and Coordination

Medical Necessity Guidelines are used together with the Member’s benefit document and in coordination with the treating physician(s) to determine coverage. Providers should review and apply the InterQual® criteria and the member’s specific benefit terms when planning care and submitting authorization requests.

Use InterQual® criteria/SmartSheets and upload completed SmartSheets when required
Check the member’s benefit document (self-insured plan variations may apply) and coordinate with treating physicians as needed
For Tufts Health Plan products, follow product-specific instructions where applicable

DescriptionBehavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the professional's time face-to-face with patient and/or guardian(s)/caregiver(s) and non-face-to-face activities including analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan.

inv-21: 97153 — technician-administered adaptive behavior treatment by protocol per 15 minutes

Code97153

DescriptionAdaptive 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.

UnitPer 15 minutes (technician-administered, one-on-one)

inv-22: 97154 — group adaptive behavior treatment by protocol per 15 minutes

Code97154

DescriptionGroup 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.

UnitPer 15 minutes (group, technician-administered)

inv-23: 97155 — adaptive behavior treatment with protocol modification, clinician-administered per 15 minutes

Code97155

DescriptionAdaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes.

UnitPer 15 minutes (clinician-administered with protocol modification)

inv-24: 97156 — family adaptive behavior treatment guidance per 15 minutes

Code97156

DescriptionFamily adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes.

UnitPer 15 minutes (family guidance)

inv-25: 97157 — multiple-family group adaptive behavior treatment guidance per 15 minutes

Code97157

DescriptionMultiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes.

UnitPer 15 minutes (multiple-family group guidance)

inv-26: H0031 — mental health assessment by non-physician

CodeH0031

DescriptionMental health assessment, by non-physician.

Prior authorizationIdentified in Table 3 as requiring prior authorization for ABA/mental health assessment services.