Currentharvard pilgrim health carePolicy N/A

Applied Behavior Analysis (ABA) therapy coverage

Defines coverage, admission/continuation/discharge criteria, limitations, and billing codes for ABA services (including early intervention) for Tufts Health RITogether members; applies to providers delivering ABA services under the plan.

Policy Summary

Payerharvard pilgrim health care

PolicyApplied Behavior Analysis (ABA) therapy coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionEnsure any required prior authorizations/notifications per product are obtained as a condition of payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Members <15 yearsage group

$5,000early intervention cap

H2014, H0046, S9446, T1013, T1016example codes

Admission/Continuation/Dischargeclinical criteria sets

Coverage and Medical Necessity Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Admission Criteria: 1. Member has received a comprehensive diagnostic and/or functional assessment (e.g., ABLLS-R, Vineland-II, ADIR, ADOS-G, CARS2, VB-MAPP, or Autism Behavior Checklist) that includes: a) complete medical history (pre- and perinatal, medical, developmental, family, social); b) physical examination (may include growth parameters, head circumference, neurologic exam); c) detailed behavioral and functional evaluation with formal diagnostic test scores and observation/history of behaviors (screening scales alone, e.g., MCHAT-R, are insufficient); and d) medical screening/testing as indicated to identify etiology, rule out treatable causes, and identify comorbidities; AND 2. Member exhibits atypical or disruptive behavior that significantly interferes with daily functioning or poses risk to the member or others (e.g., aggression, self-injury, property destruction); AND 3. Initial evaluation from a Licensed Applied Behavior Analyst supports the request for ABA services; AND 4. Diagnostic report clearly states the diagnosis and the evidence used to make that diagnosis; AND 5. For early intervention (member <3 years): valid PCP referral to early intervention and acceptance by early intervention for intensive services, with compliance with Rhode Island early intervention certification standards throughout treatment.

Admission criteria list is conjunctive; all items required.

inv-02: Continuation Therapy

Continuation of coverage when ALL of the following are met:

Continuation Criteria: 1. Member's condition continues to meet admission criteria for ABA (due to continued presenting problems or new problems/symptoms); AND 2. There is a reasonable expectation the individual will benefit from continued ABA services with an individualized treatment plan containing realistic, specific goals and objectives updated based on progress (including addition of new target behaviors); AND 3. Initial assessment from a Licensed Behavior Analyst supports continued ABA services; AND 4. Member's progress is monitored regularly (behavioral graphs, progress notes, daily session notes) and the treatment plan is modified if there is no measurable progress toward decreasing frequency/intensity/duration of target behaviors or increasing skill acquisition; AND 5. Documented skills transfer to the member and treatment transition planning from the beginning of treatment; AND 6. Documented active attempt at coordination of care with relevant providers/caregivers (or documentation of why coordination was not successful); AND 7. Parent/guardian involvement in training of behavioral techniques is documented in the medical record; AND 8. Services are not duplicative of services provided as part of an Individual Educational Plan (IEP) or Individual Service Plan (ISP) when applicable.

All items required for continued medical necessity.

inv-03: Discharge

Discharge is appropriate when ONE of the following is met:

Discharge Criteria: 1. Member's individual treatment plan and goals have been met; OR 2. Member has achieved adequate stabilization of challenging behavior and less-intensive treatment is appropriate; OR 3. Member no longer meets admission criteria or requires a different intensity of services; OR 4. Treatment is making symptoms persistently worse; OR 5. Member is not making meaningful, durable, generalized measurable improvement and there is no reasonable expectation of progress; OR 6. Home environment presents safety risks to staff; OR 7. Parent/guardian is not successfully following program rules.

Any single item suffices for discharge.

The policy excludes services that are not medically necessary or that do not meet the plan’s intent for therapeutic benefit. Specifically, ABA services are not covered when they are provided primarily for school or educational purposes, when the member has medical conditions or impairments that would prevent beneficial utilization of services, or when services require 24‑hour medical or nursing monitoring or procedures in a hospital setting. Additionally, therapies considered investigational or unproven (for example, facilitated communication, Auditory Integration Therapy, Holding Therapy, and Higashi/Daily Life Therapy) are excluded from coverage.

ABA Clinical Criteria

inv-17: ABA clinical criteria

Behavioral-health specific admission, continuation, and discharge criteria for ABA services (ASD and early intervention).

ABA Admission: See admission criteria: comprehensive diagnostic/functional assessment with formal test scores and medical screening; disruptive behavior significantly interfering with functioning or posing risk; initial evaluation supports ABA; clear diagnostic report; and for early intervention (<3 years) valid PCP referral and acceptance by early intervention program meeting RI standards.

Conjunctive criteria.

ABA Continuation: See continuation criteria: continued meeting of admission criteria; reasonable expectation of benefit with individualized, updated treatment plan and realistic goals; Licensed Behavior Analyst assessment supporting continued services; regular progress monitoring with behavioral graphs/progress notes/daily session notes and modification if no measurable progress; documented skills transfer and transition planning; documented coordination attempts with relevant providers/caretakers; documented parent/guardian training involvement; and non-duplication with IEP/ISP services.

Conjunctive criteria.

ABA Discharge: Any one discharge criterion met as listed: treatment goals met; adequate stabilization and step-down to less-intensive care appropriate; no longer meets admission criteria or requires different intensity; treatment worsening symptoms; no meaningful measurable improvement with no reasonable expectation of progress; unsafe home environment for staff; or parent/guardian not following program rules.

Single item sufficient.

Outpatient / Home-based Level of Care

inv-16: Outpatient / Home-based ABA

Level-of-care criteria for outpatient or home-based ABA (top-level considerations):

Admission (Level agnostic): Use the admission criteria listed in policy to determine need for intensive ABA services; intensity (hours per week) should be based on severity of symptoms and required treatment intensity, with services delivered by technicians supervised by a Licensed Applied Behavior Analyst across settings (home, community, agencies, hospitals).

Policy notes intensive programs and multiple settings.

Continued Stay (Level agnostic): Continued stay requires documented progress, an updated individualized treatment plan, documented skills transfer and transition planning, coordination of care, and parent/guardian involvement as specified in the continuation criteria.

All items required.

Billing Codes and Financial Limits

Associated service codesmixedCovered

H2014	Specialized treatment consultation - occupational therapist, per 15 minutes.
H2014-HO	Treatment consultation (master level clinician).
H2014-HP	Treatment consultation (doctoral level clinician).
H0046	Lead Therapy.
H0046-HO	Clinical supervision - master level clinician. Behavioral health services, not otherwise specified.
H0046-HP	Clinical supervision - doctoral level clinician. Behavioral health services, not otherwise specified.
S9446	Patient Education - Social Skills Group
T1013	Sign language or oral interpreter services, (up to 8 hours per month, 4 for supervision and 4 for parent training, not to be used with direct service).
T1016	Treatment Coordination.
T1024	Home Based Therapy - Specialized Treatment/Treatment Support

inv-07: Early intervention annual cap — $5,000 per dependent per calendar year

Annual cap amount$5,000 per dependent per calendar year

Applies toDependents under age 3 who are certified eligible for IDEA Part C services

Benefit periodPer calendar year

Plan referenceEarly intervention coverage limited to a benefit of $5,000 per dependent child member per calendar year

Provider Responsibilities and Documentation

Prior Authorization

Prior Authorization / Notification Responsibility

Prior authorization is not required for ABA therapy in all cases; however, providers are responsible for confirming and obtaining any required prior authorizations or notifications that may apply to the specific Member or service setting. Failure to obtain any required prior authorizations or to provide required notifications may result in denial or reduced payment.

Confirm Member-specific coverage and any plan-level prior authorization requirements before initiating services.
If prior authorization is required, submit supporting clinical documentation with the request (see contact/FAX instructions in header).
Failure to obtain required prior authorization or notification may affect payment.

Documentation Required

Required Evaluation Documentation

Initial evaluation must include a comprehensive diagnostic and/or functional assessment performed by qualified personnel. Assessments should use standardized instruments as appropriate and include sufficient clinical detail to justify medical necessity.

Complete medical history (pre-/perinatal, medical, developmental, family, social).
Physical examination as appropriate (e.g., growth parameters, neurologic exam).
Detailed behavioral and functional evaluation documenting behaviors consistent with ASD and comorbidities, including scores from formal diagnostic tests (examples: ABLLS‑R, Vineland‑II, ADIR, ADOS‑G, CARS2, VB‑MAPP). Screening tools alone (e.g., M-CHAT‑R) are insufficient.
Medical screening/testing to identify etiology and rule out treatable causes, as indicated.
Initial evaluation from a Licensed Applied Behavior Analyst supporting the need for ABA services.

Documentation Required

Ongoing Documentation for Continuation

For continuation of services, ongoing documentation must demonstrate clinical benefit, active treatment planning, and caregiver coordination. Lack of adequate documentation of progress or coordination may lead to non‑payment for continued services.

Updated individualized treatment plan with realistic, specific goals and objectives reflecting the Member's changing condition; document additions of new target behaviors when appropriate.
Objective progress monitoring including behavioral graphs, progress notes, and daily session notes showing measurable changes in frequency, intensity, and/or duration of targeted behaviors or gains in skill acquisition.
Documentation of skills transfer and transition planning from the outset of treatment.
Evidence of coordination with relevant providers and caregivers; if coordination attempts are unsuccessful, document reasons.
Parent/guardian involvement and training in behavioral techniques must be documented to support generalization of goals.

Step Therapy

No step therapy requirements are specified for ABA therapy in this policy.

Key Definitions

inv-14: ABA definition — Applied Behavioral Analysis as defined by BACB

DefinitionApplied Behavioral Analysis (ABA) as defined by the Behavior Analyst Certification Board: a scientific discipline that focuses on the analysis, design, implementation, and evaluation of environmental modifications to produce meaningful changes in human behavior, using direct observation, measurement, and functional analysis.

Core methodsUse of changes in environmental events (antecedents and consequences), direct observation, measurement, and functional analysis to change behavior.

Modalities includedDiscrete trial training, verbal behavioral intervention, pivotal response training (examples, not exhaustive).

Service deliveryIndividual ABA treatment plan developed by a Licensed Applied Behavior Analyst; one-on-one sessions typically provided by behavioral technicians under supervision.

inv-15: Early intervention — services for dependents birth to age three, IDEA Part C context

Age rangeDependents from birth to age three (under 3 years)

IDEA contextServices for dependents certified as eligible under Part C of the Individuals with Disabilities Education Act (IDEA).

Included servicesMay include speech/language therapy, occupational therapy, physical therapy, evaluation, case management, nutrition, service plan development and review, nursing, assistive technology services and devices.

Benefit limitationEarly intervention coverage is limited to $5,000 per dependent per calendar year under this plan.

Revision History

2025-11-19reviewLatest

Reviewed by MPAC for annual review and renewed without changes effective January 1, 2026.

2024-09-19review

Reviewed by MPAC and renewed without changes effective November 1, 2024.

2023-12-20revision

Reviewed by MPAC; removed prior authorization for ABA with early intervention services and removed requirement for autism diagnosis code for ABA per RI EOHHS; document to be maintained as a coverage guideline effective February 1, 2024.

2023-08-16review

Reviewed by MPAC and renewed without changes; template updated effective November 1, 2023.

2022-09-21review

Reviewed by MPAC and renewed without changes.

2022-04-05administrative_update

Template updated.

2021-09-15review

Reviewed by IMPAC and renewed without changes.

2021-08-18revision

Reviewed by the Medical Policy Approval Committee (MPAC); removed codes H0031, H0032, H2012, H2019, S9128, S9129, and S9131; added codes H0046, S9446, T1013, T1016, and T1024.

OpenPayer