Coverage of Intensive Behavioral Therapy for Autistic Spectrum Disorder (ASD)
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This memorandum defines coverage, billing, provider qualifications, supervision, and prior authorization requirements for intensive behavioral therapy (ABA) for individuals with ASD under Hawaii DHS Med-QUEST; it applies to QUEST Integration Health Plans and Fee-For-Service providers.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Initial and continuing coverage criteria
Covered when ALL of the following are met:
This guidance does not apply to the Department of Education’s School‑Based Claiming (SBC) program or the Department of Health’s Early Intervention (EI) program. Enrollees receiving services through SBC or EI obtain intensive behavioral therapy through those programs rather than through the child’s health plan. Contact information for policy questions is provided in the source guidance.
Services should be discontinued or not continued when the child does not continue to show response to therapy. Continued authorization is contingent on documented clinical response in submitted treatment plans and progress documentation; plans that do not justify continued hours or do not demonstrate clinical benefit may be denied or limited by the health plan.
For continuing services, the health plan requires submission of an updated treatment plan at least two weeks before the end of the current approval period so determinations can be made without disrupting care. Initial approvals cover a minimum of 6 months during the first 12 months of services; after 12 months of services, approved plans must be for no less than 3 months.
Billing, Age Limits, and Codes
| No codes listed |
Prior Authorization, Documentation, and Clinical Operations
Prior authorization required: submit CDE and functional assessment with treatment plan
Submit a completed Comprehensive Diagnostic Evaluation (CDE) and a completed functional assessment with an individualized treatment plan to the child's health plan for prior authorization of intensive behavioral therapy hours. Initial approvals are for no less than a 6-month period within the first 12 months of services; after 12 months of services, approvals shall be for no less than a 3-month period. Submit continuing treatment plans at least two weeks prior to the end of the current approved treatment so the health plan can make a determination within that period.
- CDE must include autism-specific assessments; standardized psychometric testing; assessment of general psychopathology; cognitive assessment; and assessment of adaptive behavior and communication.
- Health plan reviews the submitted treatment plan and prior authorizes the number of intensive behavioral therapy hours.
- CDE shall be repeated every 12 months.
Clinical step considerations: tailor intensity to age and developmental level
Determine medical necessity and tailor therapy intensity based on the child's age, initial developmental level, and treatment intensity, because younger age at intake, higher initial developmental levels, and higher treatment intensity are associated with better outcomes.
- Consider higher-intensity ABA (e.g., ~15 hours/week) for younger children when clinically appropriate.
- Document rationale linking chosen intensity to the child's age and developmental level in the treatment plan.
Documentation retention: keep treatment and supervisory records on file
Maintain all required documentation in the client's record and make it available upon request to the Med-QUEST Division and its authorized agents.
- Keep treatment plans, progress notes, functional assessments, completed CDEs, and supervisory notes in the client file.
- Supervising provider must review and sign treatment plans and progress notes and retain signed supervisory notes documenting at least 1 hour/month of direct individual supervision per supervisee.
Denial triggers: insufficient justification or lack of demonstrated response
Be aware the health plan may deny or limit services if the submitted treatment plan does not justify the requested number of hours or if the child is not continuing to show response to therapy.
- Ensure treatment plans include objective measures of progress and justification for requested hours.
- If a child fails to demonstrate ongoing response, therapy may be discontinued or not continued.
Clinical Evidence and Context
Evidence indicates that intensive behavioral therapy based on applied behavioral analysis (ABA) models can improve cognitive and language outcomes in some children with autism spectrum disorder, with the strongest effects observed in younger children. Outcomes are generally most favorable for children aged approximately 2–6 years, and better response has been associated with earlier treatment start, higher initial developmental level, and higher treatment intensity. Response is variable and moderated by individual child and treatment factors; therefore medical necessity and treatment intensity must be determined and tailored by the designated provider and health plan.
Key Definitions
Outpatient / Intensive Behavioral Therapy Criteria
Outpatient / Intensive Behavioral Therapy — level-of-care criteria (top-level nodes)
Treatment plan to be submitted at least two weeks prior to end of current approved treatment; determinations made within this period.
ABA Evidence and Application Notes
Clinical evidence context — ABA-based intensive behavioral therapy evidence and practical application notes
ABA-based intensive behavioral therapy evidence and practical application notes:
Based substantially on AHRQ systematic review; intensive behavioral therapy must be provided when medically necessary for individuals younger than 21 years.
ABA / Intensive Behavioral Therapy Modalities
ABA / Intensive Behavioral Therapy — modality criteria (1 top-level node)
CDE and functional assessment/treatment plan required prior to authorization; supervising designated providers/BCBAs may oversee certain unlicensed providers.
Treatment Plan Approval Periods and Limits
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