Obtain prior authorization for ABA treatment

Prior authorization (PA) is required for reimbursement of services provided under the individualized treatment plan; no PA is required for EPSDT screening provided by a PCP. Rendering providers shall request PA in hours/week for up to 26 weeks and must submit PA at least two weeks prior to the end of the approved treatment period including a re-evaluation.

• PA required for services under the treatment plan (Attachment A).
• No PA required for EPSDT services provided by a PCP (Attachment A).
• PA requests submitted in hours/week for up to 26 weeks; include re-evaluation and submit at least 2 weeks before end of approved period.

QI plans require documented progress for continued authorization

QI health plans will prior authorize ongoing ABA services only when beneficiaries demonstrate documented improvement, amelioration, or maintenance in targeted developmental areas; rendering providers may request separate PA for school‑aged beneficiaries when school is not in session.

• Continued authorization contingent on documented progress in social skills, communication, language, behavior change, or adaptive functioning.
• Separate PA may be requested for school‑aged beneficiaries when school is not in session.

Request PA when psychological testing reaches hourly cap

Psychological testing billed by MD/DO is subject to an hourly cap (MD/DO $59.90/hour) and requires prior authorization when the maximum (up to 10 hours) is reached.

• Psychological testing per hour listed as $59.90/hour for MD/DO.
• Maximum 10 hours — exceeding or reaching this maximum requires PA.

Do not bill 90791/90792 more than once per day or with E&M

Either CPT code 90791 or 90792 will be reimbursed a maximum of once per day and neither code may be billed on the same day as an evaluation and management (E&M) service.

• Only one of 90791 or 90792 reimbursed per day (max once/day).
• 90791/90792 cannot be billed the same day as an E&M service.

Report assessments and reassessments using 0359T

Assessment code 0359T may be reported for initial assessment and for reassessment; reassessment is typically required after success or failure of the current treatment plan and must be included in PA/re-evaluation materials.

• Use 0359T for behavior identification assessment for initial assessment and reassessment.
• Include reassessment findings in PA requests and re-evaluations of treatment goals.

Use specified assessment and observational codes

Report assessment and observational assessment services using the listed assessment codes (0359T, 0360T, 0361T, 0362T, 0363T) as appropriate for behavior identification, observational assessment, and behavioral follow‑up.

• 0359T — behavior identification assessment (initial and reassessment).
• 0360T/0361T — observational assessment of behavioral functioning.
• 0362T/0363T — behavioral follow‑up assessment(s).

Bill units per session and confirm qualified provider

One unit equals one session; services must be provided by BCBA‑D, BCBA, or other qualified licensed practitioners determined by DHS and billed to the rendering provider or contracting/employing agency.

• 1 unit = 1 session (assessment or therapeutic session).
• Rendering providers: BCBA‑D, BCBA, BCaBA, RBT under supervision, or diagnosing providers as within scope.
• Payment made only to the rendering provider or their contracting/employing agency.

Follow QI health plan instructions for PA workflow

The provided Attachment A excerpts do not specify operational PA submission workflows or forms in these chunks; QI health plans will determine and communicate their PA requirements and required forms.

• QI health plans shall determine and communicate PA requirements and required forms.
• No detailed operational PA workflow is specified in the cited attachment excerpts.

Limit billing of 0360T/0362T to one 30‑minute unit per day

Codes 0360T and 0362T represent the first 30‑minute IBT service and may be billed a maximum of once per day regardless of which provider delivered the service.

• 0360T/0362T = first 30 minutes of service; maximum 1 unit per day.
• Billing limited to one 30‑minute session per day irrespective of multiple providers.

Adhere to first‑30‑minute and time‑based reporting rules

0360T and 0362T are defined as the first 30‑minute service and may be billed only once per day; 0362T and 0363T are time‑based reporting codes and must follow single‑provider face‑to‑face reporting rules.

• 0360T/0362T denote first 30 minutes of service; max 1 unit/day.
• 0362T/0363T are reported based on a single provider's face‑to‑face time (see single‑provider rule).

Report 0362T/0363T based on a single provider's face‑to‑face time

When billing codes 0362T and 0363T, report only the face‑to‑face time of a single provider for that session; do not aggregate time across multiple providers.

• 0362T/0363T units must reflect a single provider's face‑to‑face minutes.
• Sequential time by the same provider within a single session may be counted; combined time from multiple providers is not reportable.

Authorize a trial of ABA up to 26 weeks when diagnosis is pending

If a diagnosing provider suspects ASD but requires further evaluation, the beneficiary may qualify for a trial of ABA of up to 26 weeks; the QI health plan may approve extensions.

• Trial ABA authorization up to 26 weeks while definitive diagnosis is completed.
• QI health plan may approve extensions or additional trial periods.

Submit assessment and individualized treatment plan with PA

The rendering provider must submit the assessment and individualized treatment plan to the QI health plan for prior authorization before treatment begins; the plan must include measurable goals with baseline, progress, anticipated timeline, treatment hours, and who will deliver services and settings.

• Include measurable goals, baselines, progress metrics, anticipated timeline and treatment hours.
• Specify who will deliver services and in which settings (clinic, home, community).

Provide required PA materials and submit claims on CMS 1500

QI health plans require consistent PA submission requirements and claims must be submitted on CMS 1500 with appropriate ICD codes by date of service; PA is required for reimbursement under the treatment plan.

• Claims for IBT services must use CMS 1500; ICD‑9 for DOS ≤9/30/2015 and ICD‑10 for DOS ≥10/1/2015.
• QI health plans will request the same set of requirements with PA requests and will communicate required forms.

Document developmental testing with interpretation and report

Document developmental testing with interpretation and report when billed (e.g., Developmental Screening Test II, Early Language, Milestone Screen); include the type of testing performed in documentation.

• Document the specific developmental test administered and include interpretation and report.
• QI health plans may reimburse practitioners performing these components and may require PA for additional testing.

Document diagnostic evaluation type and include report

For diagnostic evaluations, document the type of diagnostic evaluation or developmental testing performed and submit interpretation/report as part of the assessment documentation for billing and PA.

• Include type of diagnostic evaluation, test names, interpretation, and written report.
• Ensure diagnostic evaluations are performed by qualified diagnosing providers (not BCBA‑D/BCaBA/RBT for diagnostic evaluation).

Include reassessment (0359T) when treatment plan changes

Reassessment may be reported with assessment code 0359T and is typically required after success or failure of the current treatment plan; include reassessment in PA/re‑evaluation submissions.

• Use 0359T to report reassessment when treatment goals need revision.
• Include reassessment results in PA requests for continued authorization.

Ensure assessments include standardized test administration and reporting

Documentation must support administration and interpretation of standardized and non‑standardized tests, detailed behavioral history, patient observations, caregiver interview/interpretation, discussion of findings, recommendations, and preparation of a report.

• Record administration and scoring of tests, observations, and caregiver interview content.
• Provide interpretation, discussion of findings, recommendations, and a written report to caregivers and practitioners.

Document single‑provider face‑to‑face time for 0362T/0363T

When billing 0362T/0363T, documentation and claims must reflect only the face‑to‑face time of a single provider during the session; do not combine time from multiple providers.

• Report only the minutes one provider spent face‑to‑face with the patient for 0362T/0363T.
• Aggregating multiple providers' face‑to‑face time for the same session is not permitted.

Base units on a single provider's face‑to‑face time

Units are based on a single provider's face‑to‑face time; sequential time by the same provider in a single session may be counted, but combined time across providers must not be billed as a single unit.

• 1 unit = 30 minutes based on individual provider's face‑to‑face time.
• Sequential minutes by the same provider within a session may be totaled for billing; do not pool time from multiple providers.

Risk of denial if PA or progress documentation not provided

PA is required for reimbursement under the treatment plan; QI health plans will prior authorize ongoing services only when beneficiary demonstrates documented improvement, amelioration, or maintenance in targeted areas — failure to obtain or meet PA conditions risks denial of reimbursement.

• Obtain PA and demonstrate documented progress per the treatment plan to receive continued authorization.
• Failure to submit required PA materials or to demonstrate progress may result in denied claims.

Non‑coverage triggers that may cause denial

Services will not be covered when care is primarily custodial; the beneficiary is not medically stable; services are provided by family or household members; services are provided as LTSS, HCBS, or respite; treatments are experimental; or services are provided by a Hawaii provider outside the State.

• Do not bill for custodial care or services by family/household members.
• Ensure beneficiaries are medically stable and services are not classified as LTSS/HCBS/respite.
• Avoid billing for experimental treatments or services provided by out‑of‑state Hawaii providers.

PA required when psychological testing exceeds 10 hours

Psychological testing per hour for MD/DO is listed at $59.90/hour with a maximum of 10 hours; reaching this maximum requires prior authorization and may trigger additional documentation requirements.

• MD/DO psychological testing rate listed as $59.90/hour.
• Max 10 hours — PA required when the cap is reached.

Ensure qualified diagnosing provider performs diagnostic evaluation

Diagnostic evaluations for ASD may not be performed by BCBA‑D, BCaBA, or RBT (technician); diagnostic evaluation must be performed by an authorized diagnosing provider and only one of 90791 or 90792 will be reimbursed per day.

• Diagnostic evaluation must be performed by licensed diagnosing providers (e.g., developmental pediatrician, psychiatrist, psychologist).
• 90791/90792 reimbursement limited to one per day.

Avoid billing 90791/90792 with same‑day E&M

Do not bill 90791/90792 on the same day as an evaluation and management (E&M) service; billing conflicts or exceeding daily limits may result in claim denial.

• 90791/90792 cannot be billed the same day as an E&M service.
• Only one of 90791 or 90792 reimbursed per day.

Do not bill multiple 30‑minute units per day or combine providers' time

Billing more than one 30‑minute session per day (e.g., billing multiple 0360T/0362T units) or combining multiple providers' time for the same session triggers noncompliance with unit maximums and may be denied.

• Maximum of 1 unit (30 minutes) per day for 0360T/0362T regardless of multiple providers.
• Do not combine face‑to‑face time across providers when reporting time‑based codes.

Adhere to single‑unit and single‑provider reporting limits

Do not bill more than one unit of 0360T or 0362T per day, and do not combine face‑to‑face time across providers when reporting 0362T/0363T; such billing violates reporting limits and may result in denial.

• 0360T/0362T — max 1 unit per day.
• 0362T/0363T — report only single provider's face‑to‑face time; do not aggregate multi‑provider time.

Report 0362T/0363T using single‑provider face‑to‑face time only

Codes 0362T and 0363T must be reported based only on a single provider's face‑to‑face time with the patient; billing that aggregates multiple providers' time for these codes may be denied.

• Report 0362T/0363T units using the minutes spent by one provider with the patient.
• Only the face‑to‑face time of any one provider during a session may be billed for those codes.