Eligibility and referral: Member is <21 years of age; recommendation from a licensed physician, surgeon, or psychologist; member is medically stable; member with intellectual disabilities does not require 24‑hour medical/nursing monitoring or hospital/ICF services.
Provider qualifications: Services provided and supervised by a qualified autism service provider, qualified autism service professional, or qualified autism service paraprofessional per applicable definitions and state licensure.
Behavior assessment report: Completed prior to requesting treatment services and includes record review; clinical interview; risk/safety assessment (as applicable); at least one of functional analysis, skills‑based assessment, or standardized assessment; assessments from other professionals (if applicable); scoring/analysis of standardized testing; treatment setting/environmental analysis; direct observation and measurement of behavior; and priority target behaviors with identification, operational definition, baseline data, and proposed goals/objectives.
Initial treatment plan: Treatment plan completed by an approved provider aligned with the assessment and containing individualized measurable goals/objectives and timelines (including age and baseline), operational definitions, interventions focused on core symptoms and generalization plan, date of introduction and estimated date of mastery, treatment setting, number of hours/units requested specifying focused (10–25 hrs) or comprehensive (30–40 hrs), parent/caregiver training, case supervision, assessment activities, coordination of care (identified providers and dates/outcomes), crisis plan, transition/titration/discharge plan with specific titration goals and discharge criteria, and signature/credential/role of each reviewer/signatory.
Continuation records: Updated behavior assessment and treatment plan at least every six months (or sooner if clinically appropriate or state mandated) including data and graph representation of mastery, changes in standardized assessment scores, changes from the initial plan, outcome measures, transition plan with monitoring/evaluation, and documentation of collaboration/coordination with other providers.every 6 months
Service activity notes: Notes completed prior to claim submission: registered technician notes documenting primary target areas, techniques used, and barriers; qualified healthcare professional notes documenting target areas observed, protocol modifications, direction of technicians, direct treatment if applicable, and caregiver consultation/training; and identification information on each note (provider organization name, member name, DOB or unique identifier, date of service, note creation date, start/end times, pauses, location, service code/type, rendering clinician/technician name/credentials/dated signature, participants and relationships), with any addenda clearly referencing the original note and date.