Harvard Pilgrim ABA Therapy Coverage Update

Coverage and Medical Necessity Criteria

Medical Necessity / Coverage Criteria

Covered when ALL of the following are met

Core coverage criteria: Member has a definitive diagnosis of Autism Spectrum Disorder (ICD-10 F84.x) and/or Down Syndrome when applicable; the requested ABA services are included in the Member's benefit; services meet medical necessity per the specified InterQual subsets/SmartSheets; parent/legal guardian involvement and training are planned.

InterQual SmartSheets listed in policy must be used for prior authorization

The Plan considers the following services to be exclusions for ABA therapy when determining coverage: services that are primarily educational in nature; services provided by school personnel pursuant to an Individual Education Program (IEP) and therefore not subject to reimbursement; treatments that are investigational or unproven (including but not limited to facilitated communication, Auditory Integration Therapy, Holding Therapy, Higashi/Daily Life Therapy); and personal training or life coaching.

Coverage for self-insured plans may differ based on the member's benefit document; when there is a conflict between this Medical Necessity Guideline and a self-insured member's benefit document, the benefit document governs. For Tufts Health Together (Medicaid), pediatric members under age 21 may have additional coverage available under EPSDT, subject to prior authorization and applicable regulatory requirements.

ABA therapy is considered not medically necessary when it meets any of the following: the service is primarily educational in nature; the service is provided by school personnel under an IEP (and thus not reimbursable); the treatment is investigational or unproven (examples listed in policy); or the service is essentially personal training or life coaching.

Diagnosis and Procedure Codes

Covered ICD-10 Diagnoses (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.

Additional ICD-10 Diagnoses (Down Syndrome) - Massachusetts products 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 AuthorizationmixedCovered

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.
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 the 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, 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.
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, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior.
0373T	Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior.

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CPT/HCPCS Codes requiring prior authorizationmixedCovered

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.

Additional ABA procedure code (prior authorization required)CPTCovered

0373T

Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient requiring administration by onsite qualified health care professional with two or more technicians for a patient who exhibits destructive behavior.

Service time unit

Service time unitper 15 minutes

Applies toAssessment and treatment CPT/CPT‑like codes listed (e.g., 97151–97157, 0373T)

Billing implicationReport units in 15‑minute increments as specified by individual code definitions

Authorization, Documentation, and Denial Guidance

Prior Authorization

Prior Authorization Required for ABA Services

Prior authorization is required for Applied Behavioral Analysis (ABA) services. Use the specified InterQual SmartSheets listed by service type to request authorization via HPHConnect; completed SmartSheets and any required clinical documentation must be submitted to the plan (see contact/fax instructions).

InterQual SmartSheets required: Initial Applied Behavior Analysis Assessment; ABA Program Assessment; ABA Consultation with other providers/agencies/school personnel; ABA Parent/Caregiver Training; ABA Supervision; ABA Treatment.
Submit completed SmartSheets and clinical documentation via HPHConnect Clinical Upload or secure fax (800-232-0816).
Providers may view InterQual criteria and questionnaires in HPHConnect (Select Researched > InterQual link) or call Provider Service Center at 800-708-4414.
Members may access materials via Member Login at www.harvardpilgrim.org or call Member Services at 888-333-4742.

Prior Authorization

Prior Authorization Required — Listed ABA-related Codes

The following CPT/HCPCS codes require prior authorization. Requests that do not obtain prior authorization may be denied or subject to retrospective review.

Authorization Components and Service Criteria

ABA authorization components

InterQual SmartSheets required for specific ABA service components

InterQual components: Authorization must reference the specific InterQual SmartSheet subset needed: Initial Applied Behavior Analysis Assessment; Applied Behavior Analysis (ABA) Program - Applied Behavior Analysis Assessment; Applied Behavior Analysis (ABA) Program - Consultation with other providers/agencies/school personnel; Applied Behavior Analysis (ABA) Program - Parent or Caregiver Training; Applied Behavior Analysis (ABA) Program - Supervision; Applied Behavior Analysis (ABA) Program - Treatment.

Use Massachusetts Standard Form for MA plans; Autism Spectrum Disorder Services form for other states

ABA service authorization summary

Policy references criteria and code-specific requirements for ABA services and notes modifications to InterQual criteria for ages 13-21.

Authorization and coding requirements: ABA services billed with the listed CPT/HCPCS codes require prior authorization and must be documented per code definitions (including time, provider type, and face-to-face vs. non-face-to-face components).

ABA Treatment Modalities

ABA

Modalities included: Assessment, program development, consultation, parent/caregiver training, supervision, and direct ABA treatment as defined by the InterQual subsets/SmartSheets.

Parent/legal guardian involvement is considered essential to treatment success

ABA (Applied Behavior Analysis)

Technician-administered ABA: Codes 97153 and 97154 describe technician-administered adaptive behavior treatment by protocol delivered face-to-face in 15-minute units under the direction of a qualified professional.per 15 minutes

Physician/qualified professional-administered ABA: Codes 97155 and 0373T describe adaptive behavior treatment with protocol modification administered by a physician or other qualified health care professional; 0373T requires the professional on site with assistance of two or more technicians for patients exhibiting destructive behavior in a customized environment.

Definitions and Procedure Descriptions

Applied Behavioral Analysis (ABA) — definition summary

DefinitionApplied Behavioral Analysis (ABA) is the design, implementation, and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in behavior; includes direct observation, measurement, and functional analysis. Parent/legal guardian involvement and training are considered essential.

ScopeIncludes assessment, program development, consultation, parent/caregiver training, supervision, and direct ABA treatment as defined by InterQual SmartSheets and code-specific definitions.

Coverage contextCovered for members with a definitive diagnosis of Autism Spectrum Disorder and, for applicable Massachusetts plans, Down Syndrome when medically necessary and benefit is part of member's plan.

97151 — Behavior identification assessment definition/notes

Code97151

Background

Applied Behavioral Analysis (ABA) is the systematic design, implementation, and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant behavior change. ABA includes direct observation, measurement, and functional analysis of environment–behavior relationships, and typically requires parent or legal guardian involvement and training to support long‑term outcomes. Medical Necessity Guidelines describe when ABA is considered appropriate and how coverage decisions are made in coordination with the member's benefit document and treating clinicians.

OpenPayer

Applied Behavioral Analysis (ABA) Therapy — Coverage Criteria