CurrentHealthy Blue LouisianaPolicy BLAPEC-0715-18

Healthy Blue Medicaid Applied Behavioral Analysis Utilization Management Guidelines

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This policy governs coverage, provider qualifications, clinical criteria, treatment planning, documentation, and prior authorization for applied behavior analysis (ABA)-based therapy for Healthy Blue Louisiana Medicaid recipients, primarily those under age 21. Covered ABA must be medically necessary, prior authorized, delivered under an approved behavior treatment plan, and provided or supervised by appropriately licensed or certified professionals.

Policy Summary

PayerHealthy Blue Louisiana

PolicyApplied Behavioral Analysis Utilization Management Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFebruary 1, 2018

Next Review DateN/A

Key ActionSubmit prior authorization requests for all ABA services through the e-PA process using the individual attending provider number, not the group provider number.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Under 21Eligible recipient age

All servicesPrior authorization requirement

180 daysMaximum authorization period

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CurrentHealthy Blue LouisianaPolicy BLAPEC-0715-18

Healthy Blue Medicaid Applied Behavioral Analysis Utilization Management Guidelines

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Policy Summary

PayerHealthy Blue Louisiana

PolicyApplied Behavioral Analysis Utilization Management Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFebruary 1, 2018

Next Review DateN/A

Key ActionSubmit prior authorization requests for all ABA services through the e-PA process using the individual attending provider number, not the group provider number.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Under 21Eligible recipient age

All servicesPrior authorization requirement

180 daysMaximum authorization period

Initial assessment limit

46 minutesBilling threshold for one-hour unit

Coverage Criteria

Initial medical necessity

ABA-based services are covered for Medicaid recipients under age 21 when ALL of the following criteria are met.

Initial ABA medical necessity: The recipient exhibits behavioral excesses and/or deficits that significantly interfere with home or community activities, such as aggression, self-injury, or elopement; the behaviors are described by frequency, severity, and duration; the comprehensive diagnostic evaluation and person-centered behavior treatment plan require ABA; the recipient has a condition for which ABA-based therapy is therapeutically appropriate, including autism spectrum disorder diagnosed by a qualified health care professional; a qualified health care professional has completed the comprehensive diagnostic evaluation; and a qualified health care professional has prescribed ABA-based therapy services.Under 21 years of age

All criteria must be met.

Comprehensive diagnostic evaluation

The comprehensive diagnostic evaluation must include, at minimum, the following elements.

Required evaluation elements: The evaluation includes a thorough clinical, developmental, and psychosocial history obtained with the informed parent or caregiver; direct observation of current social, communicative, play, and peer-interaction functioning; review of available records; a valid DSM-V or current-edition diagnosis; rationale for referral or non-referral for an ABA functional assessment and possible ABA services; and recommendations for additional treatment, care or services, specialty referrals or consultations, standardized measures, laboratory studies, or other diagnostic evaluations when clinically appropriate or medically necessary.

When screening is borderline or the primary diagnosis, comorbid conditions, or medical necessity is unclear, include age- and cognitively appropriate autism-specific, general psychopathology, cognitive, and adaptive behavior assessments.

Behavior treatment plan

The behavior treatment plan must satisfy ALL applicable requirements.

Behavior treatment plan standards

Required plan elements: The plan is person-centered and individualized; documents baseline frequency, severity, and duration; defines behaviorally stated long-, intermediate-, and short-term goals and objectives; specifies achievement and measurement criteria; identifies the service schedule and responsible providers; includes care coordination and caregiver training, support, and participation; uses specific, measurable objectives tailored to the recipient; and applies ABA-consistent interventions.
Observation and service details: The plan documents that direct observation occurred and describes its findings; identifies reported behaviors that were not directly observed, including documented situations and frequencies; attaches documentation from other sources; reports other evidence supporting the behaviors; specifies expected weekly hours and service locations; states requested treatment intensity and frequency with justification; and includes the IEP or explains why it cannot be provided.
Waiver coordination when applicable: For a recipient in a waiver, the plan identifies the waiver, includes the Plan Profile Table and Schedule page from the certified plan of care, maintains communication with the waiver support coordinator, and documents any overlap between ABA and waiver services in an addendum.

Parent and caregiver participation

Caregiver-related services should be included in the behavior treatment plan for prior authorization.

Parent and caregiver participation: Treatment planning includes care coordination with the parent or caregiver and parent/caregiver training, support, and participation. Family adaptive behavior treatment guidance transfers skills to parents or caregivers to promote consistency across environments and reinforce therapy at home and other locations.

Multiple-family group guidance may be included when caregivers of two or more recipients with similar diagnoses, behaviors, and treatment needs are present.

Continued ABA therapy

Continued authorization requires ALL of the following.

Continued ABA stay: The individual continues to meet the criteria for an initial course of applied behavior treatment; the person-centered behavioral treatment plan is updated and submitted every 6 months or as required by a state mandate; and the authorization period does not exceed 180 days.Authorization period no more than 180 days; treatment-plan update every 6 months

A comprehensive diagnostic evaluation completed more than 18 months before the authorization request may require an update, progress report, or re-evaluation by a qualified health care professional.

Not medically necessary or excluded services

Services are not medically necessary or reimbursable when any applicable exclusion applies.

Excluded or non-medically-necessary services: Measurable functional improvement or continued clinical benefit is not expected; the service is not necessary or expected for maintenance of function or prevention of deterioration; the service is primarily educational, vocational, or recreational; the service duplicates IFSP or IEP services outside the school setting; the service is custodial care primarily assisting with activities of daily living or safety; the service could be provided by a person without professional skills or training; the service is performed in a non-conventional setting such as a resort, spa, therapeutic program, or camp; the service is experimental, non-FDA-approved, investigational, or cosmetic; or the service is rendered by a parent, legal guardian, or legally responsible person.

These services do not qualify as Medicaid-covered ABA-based therapy. School-based ABA also requires an IEP provided to the Louisiana Department of Health.

Medical necessity definition

A service is medically necessary only when ALL of the following standards are met.

General medical necessity standard: The service conforms to generally accepted evidence-based medical standards or the community professional standard of care; is reasonably necessary to diagnose, correct, cure, alleviate, or prevent worsening of a condition that endangers life, causes suffering or pain, or results or may result in handicap, physical deformity, or malfunction; has no equally effective, more conservative, less costly, suitable alternative; and is individualized, specific, and consistent with the symptoms or confirmed diagnosis, and neither more nor less than the recipient requires at that point in time.Individualized; no equally effective, more conservative, less costly suitable alternative

Experimental, non-FDA-approved, investigational, and cosmetic services are excluded from Medicaid coverage and deemed not medically necessary, subject to possible case-by-case Medicaid director discretion.

School-based ABA services will not be approved until an Individualized Education Program (IEP) is provided to the Louisiana Department of Health (LDH). ABA therapy recommended in an IEP and delivered by the Local Education Authority may be reimbursable when all other coverage requirements, including medical necessity, are met.

ABA-based therapy is not covered when its primary purpose is educational, vocational, recreational, or custodial. Services delivered outside the school setting that duplicate services under an Individualized Family Service Plan (IFSP) or IEP are excluded. Coverage also excludes services that could be provided by untrained persons or services performed in non-conventional settings, including resorts, spas, therapeutic programs, and camps.

Reimbursement is not available for ABA services rendered by, or on behalf of services rendered by, a parent, legal guardian, or legally responsible person.

Experimental, non-FDA-approved, investigational, and cosmetic services are excluded from Medicaid coverage and are deemed not medically necessary. The Medicaid director, in consultation with the Medicaid medical director, may consider authorization on a case-by-case basis at the director’s discretion.

ABA services are not medically necessary when the applicable criteria are not met, including when measurable functional improvement or continued clinical benefit is not expected, or when services are not necessary or expected for maintenance of function or prevention of deterioration.

Covered Services and Coding

ABA-based therapy and assessment procedure codesCPT

0359T TG	Assessment (LBA); initial assessment only, 1 hour
0359T	Assessment (SCABA); initial approval of three hours for first assessment; additional hours only if medically necessary
0360T	Follow-up assessment (LBA), first 30 minutes
0360T TF	Follow-up assessment (SCABA), first 30 minutes; 1 every six months
0360T	Follow-up assessment (Tech), first 30 minutes
0361T	Follow-up assessment (LBA), additional 30 minutes
3061T	Follow-up assessment (SCABA), additional 30 minutes; 7 every six months, more if medically necessary
3061T	Additional 30 minutes follow-up assessment (Tech)
0364T	Adaptive behavior treatment by protocol (LBA), first 30 minutes
0364T	Adaptive behavior treatment by protocol (SCABA), first 30 minutes; once daily as prior authorized

1–10 of 30

1/3

One-hour billing unit

Billing unitOne-hour unit

Minimum service time46 minutes or more

Billing requirementAt least 46 minutes of service must be provided to bill one unit

30-minute billing unit

Billing unit30-minute unit

Minimum service time16 minutes or more

Billing requirementAt least 16 minutes of service must be provided to bill one unit

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required for All ABA Services

All ABA services require prior authorization before delivery. Recipients must select an available Medicaid-enrolled provider of their choice.

Submit through the fiscal intermediary’s Prior Authorization Unit (PAU) using the electronic prior authorization (e-PA) process.
Use the individual attending provider number; do not use the group provider number on the e-PA.

Prior Authorization

Submit the ABA Therapy Authorization Request

Submit a separate authorization request to provide ABA-based therapy services. The request must include the clinical and treatment documentation needed for review.

Include the Comprehensive Diagnostic Evaluation (CDE), behavior treatment plan, Individual Education Plan (IEP), and applicable waiver documentation.
ABA-derived therapy authorizations may not exceed 180 days.

Policy Background

Applied behavior analysis (ABA) is an evidence-based therapeutic approach that uses direct observation, measurement, functional analysis, environmental modification, reinforcement, and prompting to teach targeted skills and produce socially significant improvement in behavior. Services may address behavioral excesses or deficits that interfere substantially with functioning in the home, school, or community, with treatment individualized to the recipient’s clinical needs.

Definitions

Applied behavior analysis

TermApplied behavior analysis

Core methodDesign, implementation, and evaluation of environmental modifications using behavioral stimuli and consequences

Clinical purposeProduce socially significant improvement in human behavior through direct observation, measurement, and functional analysis

Serious Emotional Disturbance

PopulationChildren and youth

ConditionA diagnosable mental, behavioral, or emotional disorder within the past year

Functional impact

Level of Care Criteria

ABA-based therapy

Continued ABA-based therapy requires continued eligibility and current authorization.

ABA-based therapy level of care: The individual continues to meet the criteria for an initial course of applied behavior treatment; the person-centered behavioral treatment plan is updated and submitted every 6 months or as required by a state mandate; and the service remains within the authorized period.Authorization period no more than 180 days; treatment-plan update every 6 months

A comprehensive diagnostic evaluation completed more than 18 months before the authorization request may require an update, progress report, or re-evaluation by a qualified health care professional.

Applied Behavior Analysis Criteria

ABA medical necessity

ABA is covered for Medicaid recipients under age 21 when ALL medical-necessity criteria are met.

ABA eligibility: The recipient exhibits behavioral excesses and/or deficits that significantly interfere with home or community activities; ABA is required in the comprehensive diagnostic evaluation and person-centered behavior treatment plan; the recipient has a condition for which ABA-based therapy is therapeutically appropriate, including autism spectrum disorder diagnosed by a qualified health care professional; a qualified health care professional has completed the comprehensive diagnostic evaluation; and a qualified health care professional has prescribed ABA-based therapy services.Under 21 years of age

All criteria must be met.

ABA treatment planning

The ABA behavior treatment plan must be individualized, measurable, developmentally appropriate, and coordinated across settings.

Treatment plan criteria: The plan addresses relevant communication, sociability, self-care, play, leisure, motor, or academic skills; defines baseline behaviors and measurable short-, intermediate-, and long-term goals; specifies achievement criteria, services, providers, locations, intensity, frequency, and justification; includes direct-observation findings, caregiver participation, and care coordination; and includes IEP or waiver coordination when applicable.

Treatment Modalities

Applied behavior analysis

Applied behavior analysis must meet ALL of the following modality requirements.

ABA-based therapy: Services use the design, implementation, and evaluation of environmental modifications through behavioral stimuli and consequences, including direct observation, measurement, and functional analysis of relationships between environment and behavior; services use behavioral observation, reinforcement, or prompting to teach each step of targeted behaviors and produce socially significant improvement.

Services must be medically necessary, prior authorized, and delivered in accordance with the behavior treatment plan.

Family adaptive behavior treatment guidance

Family adaptive behavior treatment guidance must meet the following requirements.

Family adaptive behavior treatment guidance: Caregiver guidance is included in the behavior treatment plan for prior authorization and transfers skills to parents or caregivers to promote consistency across environments and reinforce therapy at home and other locations.

Multiple-family group guidance is used when caregivers of two or more recipients with similar diagnoses, behaviors, and treatment needs are present.

Visit and Authorization Limits

ABA-based therapy authorization

ServiceABA-based therapy

Authorization periodNot to exceed 180 days

Authorization typeABA-derived therapy services require a separate provider authorization request

Initial behavior identification assessment

ServiceBehavior identification assessment by a non-physician

MaximumFour hours per evaluation authorization

Review exceptionAdditional hours require review and approval by the Bureau of Health Services Financing

Policy Summary

PayerHealthy Blue Louisiana

PolicyApplied Behavioral Analysis Utilization Management Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFebruary 1, 2018

Next Review DateN/A

Key ActionSubmit prior authorization requests for all ABA services through the e-PA process using the individual attending provider number, not the group provider number.

SourceLink

On This Page

SCABA follow-up assessment

Code3061T

Service limitSeven units every six months

ExceptionMore units may be provided if medically necessary

Additional LBA supervision

ServiceLBA supervision, additional 30 minutes

Weekly limitUp to one unit per week unless otherwise clinically indicated

Percentage limitUp to a maximum of 10 percent of approved weekly therapy units

Prior Authorization

Authorize Functional Assessment and Plan Development

Obtain prior authorization before conducting the functional assessment and developing the behavior treatment plan. The request must include a CDE completed by a qualified health care professional (QHCP) who prescribes or recommends ABA services.

Request follow-up assessments 45 days before the ABA renewal date; no documentation is required with that follow-up request.
A CDE older than 18 months may require an update, progress report, or QHCP re-evaluation.
PAU decisions are entered in e-PA and are available for provider review the following business day; decision letters are also sent to applicable parties.

Billing Rule

Initial Assessment Limit

For the initial assessment, behavior identification assessment by a non-physician requires prior authorization and is limited to four hours per evaluation authorization unless the Bureau of Health Services Financing (BHSF) reviews and approves more.

Only one initial-assessment authorization is approved for the first 180 days of ABA services unless circumstances warrant an additional evaluation.
Request any additional evaluation with a full explanation; approval is case-by-case by the Medicaid medical director.

Note

Request Reconsideration of Authorization Decisions

If a request is denied, not approved as requested, or an existing authorization must be changed, submit a reconsideration request to the prior authorization process.

Place “Recon” across the top of the prior authorization decision notice and state the reason across the bottom.
Include the original submission and all additional information supporting reconsideration.
A new notification letter with the same prior authorization number will be issued after review.

Denial Risk

All Medical-Necessity Criteria Must Be Met

ABA-based services are medically necessary only when all qualifying requirements are satisfied. Failure to meet any one criterion makes the services not medically necessary.

The recipient must be under age 21 and have behavior excesses or deficits that significantly interfere with home or community activities.
The CDE and person-centered behavior treatment plan must require ABA, and a QHCP must diagnose a condition for which ABA is therapeutically appropriate.
A QHCP must complete the CDE and prescribe ABA-based therapy services.

Denial Risk

Use the Correct Prior Authorization Submission

Submit every prior authorization request electronically through e-PA using the individual attending provider number. Incorrect submission routing can prevent proper processing.

Do not submit the request under the group provider number.
For adaptive behavior treatment protocol and group adaptive behavior treatment protocol, modifiers are added at claim submission rather than requested during authorization.

Documentation Required

Initial ABA Request Documents

For an initial ABA therapy request, assemble the complete clinical and service-plan record before submission.

Comprehensive Diagnostic Evaluation (CDE).
Behavior treatment plan.
Individual Education Plan (IEP).
If the recipient is in a waiver and services overlap, include the waiver plan profile table and schedule from the certified plan of care.

Documentation Required

Comprehensive Diagnostic Evaluation Content

Ensure the CDE contains sufficient clinical, developmental, observational, and diagnostic information to support the ABA request.

Thorough clinical, developmental, psychosocial, and caregiver history.
Direct observation addressing current social, communicative, play, or peer-interaction functioning; review available records.
A valid DSM-5 or current-edition diagnosis and rationale for referral or non-referral for ABA functional assessment and services.
Recommendations for additional treatment, referrals, consultations, standardized measures, laboratory work, or other clinically appropriate evaluations.
When screening is borderline or diagnosis, comorbidities, or medical necessity is unclear, include autism-specific, general psychopathology, cognitive, and adaptive-behavior assessments appropriate to age and cognitive abilities.

Documentation Required

Behavior Treatment Plan Requirements

Develop a person-centered, individualized behavior treatment plan with measurable objectives, documented baseline behavior, and coordinated implementation.

Document frequency, severity, duration, long-, intermediate-, and short-term behavioral goals, measurement criteria, service schedule, responsible providers, and requested intensity with justification.
Include direct-observation findings, supporting records for reported behaviors not observed, and a weekly schedule showing hours and service locations.
Include care coordination, parent or caregiver training and participation, and the recipient’s IEP or an explanation for why it cannot be provided.
For waiver recipients, include the plan profile table and schedule page and document any ABA/waiver overlap in an addendum.

Documentation Required

Direct Support Worker Addendum

When the ABA provider and direct support worker must be present together, add a specific, time-limited, measurable, individualized addendum to the behavior treatment plan.

Document joint-session frequency and duration and the information needed for correct implementation.
Define measurable competency goals and methods for collecting performance data.
Describe demonstration, modeling, coaching, feedback, and repeated practice opportunities.

Billing Rule

Maintain Credential and Modifier Documentation

Retain documentation demonstrating that the credentials of the person performing each service match the modifier reported on the claim.

Modifiers generally do not need to be requested during prior authorization for applicable adaptive behavior treatment protocols; add them at claim submission.
Maintain credential-to-modifier documentation in the provider’s records.

Documentation Required

Document Direct Support Worker Competency

For direct support worker competency, document how the ABA provider will train, observe, and evaluate implementation during joint services.

Specify session frequency and duration, implementation instructions, objective competency goals, and performance-data collection.
Identify individualized strategies such as demonstration, modeling, coaching, feedback, role play, and practice in real-life situations.

Prior Authorization

Submit Continued-Stay Documentation

For continued authorization, submit an updated person-centered behavior treatment plan every six months or sooner when required by a state mandate.

The authorization period may not exceed 180 days.
Document that the recipient continues to meet the initial-course ABA criteria.
Update the CDE, progress report, or obtain QHCP re-evaluation when the CDE is more than 18 months old or an update is required.

Documentation Required

Supervision and Treatment-Plan Oversight

The licensed professional must oversee and manage the treatment team throughout care and adjust the behavior treatment plan as needed.

Provide supervision and consultation to the recipient’s team.
Conduct regular family meetings to plan, review progress, and make treatment-plan adjustments.
Perform part of the supervision in the recipient’s presence with the state-certified assistant behavior analyst or registered line technician.

Denial Risk

IEP Required for School-Based Requests

A school-setting behavior treatment plan will not be approved until an IEP is provided to the Louisiana Department of Health (LDH).

Include the IEP with the request or explain why it cannot be furnished.
IEP-recommended ABA delivered by the Local Education Authority may be reimbursable when all other coverage conditions, including medical necessity, are met.

Denial Risk

Maintain Provider Credentialing and Eligibility

Maintain all provider credentialing and eligibility requirements to preserve reimbursement eligibility.

Providers must be appropriately licensed, certified, or registered and supervised as required.
The provider and rendering staff must have no applicable Medicare or Medicaid sanctions and must not be excluded from federally funded programs, including OIG-LEIE, SAM, or state Medicaid exclusion listings.

Denial Risk

Avoid Medical-Necessity and Exclusion Denials

ABA services are not medically necessary or covered when the required criteria are absent or the service falls within an excluded purpose.

Do not bill services when measurable functional improvement or continued clinical benefit is not expected and maintenance or deterioration prevention is not needed.
Excluded purposes include primarily educational, vocational, recreational, custodial, or nonprofessional services; duplication of IFSP/IEP services; and services in nonconventional settings such as resorts, spas, therapeutic programs, or camps.

Denial Risk

Verify Eligibility and Authorization Before Service

Verify Medicaid eligibility before providing services and obtain authorization before rendering care. Services without authorization are not reimbursable except for retroactive Medicaid eligibility.

Reimbursement is limited to services authorized by Medicaid or its designee and delivered by enrolled, appropriately licensed providers.
Services rendered by a parent, legal guardian, or legally responsible person are not reimbursable.

Denial Risk

Nonreimbursable Services and Provider Conditions

Reimbursement is available only for authorized ABA services provided by enrolled, currently licensed and eligible providers.

A prior authorization period may not exceed 180 days.
Confirm the recipient’s Medicaid eligibility before each course of services and maintain authorization documentation.
Do not seek reimbursement for services provided by a parent, legal guardian, or legally responsible person.

Impairment that substantially interferes with or limits functioning in family, school, or community activities

ABA-based therapy

TermABA-based therapy

Intervention methodBehavioral observation and reinforcement or prompting

Skill developmentTeaches each step of targeted behavior

Comprehensive Diagnostic Evaluation

TermComprehensive Diagnostic Evaluation

Performed byA qualified health care professional

PurposeEstablish medical necessity, diagnosis, functional concerns, and the rationale for referral to ABA assessment and services

Qualified Health Care Professional

Qualifying professionalsPediatric neurologist, developmental pediatrician, psychologist or medical psychologist, or psychiatrist

Scope of practiceIncludes differential diagnosis of autism spectrum disorder and comorbid disorders for the recipient’s age or cognitive level

Experience requirementAt least two years providing diagnostic assessments and treatments

Serious Emotional Disturbance (SED)

PopulationChildren and youth

ConditionA diagnosable mental, behavioral, or emotional disorder within the past year

Functional impactImpairment that substantially interferes with or limits functioning in family, school, or community activities

Supervision

Responsible professionalLicensed professional

Team oversightProvides case oversight and management, and supervises and consults with the recipient’s team

Treatment oversightConducts family meetings, reviews progress, and adjusts the behavior treatment plan

Camp

TermCamp

Facility typeRecreational, educational, or instructional facility

DurationUsually time limited

Resort

TermResort

PurposeA place frequented by people that offers visitor services and activities

ExamplesFood, drink, lodging, sports, recreational or entertainment activities, or shopping

Spa

TermSpa

Business typeBusiness providing health and relaxation services

ServicesWeight management, skin care, and fitness services

Therapeutic Program

TermTherapeutic Program

ActivitiesRecreation, arts and crafts, drama, wilderness, equine, or other activities

PurposeIntended to address a medical problem, particularly for children and adolescents

ABA service delivery and continued treatment

ABA-based services are covered when medically necessary, authorized, appropriately supervised, and delivered under an approved behavior treatment plan.

ABA service delivery and continued treatment: Services use behavioral observation, measurement, functional analysis, environmental modification, reinforcement, or prompting to teach targeted behaviors and produce socially significant improvement; services are delivered by or under the supervision of an appropriately licensed professional; services are provided in a natural setting such as the home, community, clinic, or school; group services are face-to-face with two or more patients with similar diagnoses, behaviors, and treatment needs; and continued treatment is provided under an updated person-centered behavioral treatment plan.Prior authorization required; authorization period no more than 180 days; treatment-plan update every 6 months

Medically necessary ABA services provided by enrolled licensed professionals in school settings are allowed.

Therapeutic behavioral services

Therapeutic behavioral services must meet ALL of the following modality requirements.

Therapeutic behavioral services: Services include the design, implementation, and evaluation of environmental modification using behavioral stimuli and consequences; direct observation, measurement, and functional analysis of the relationships between environment and behavior; and one-on-one teaching of each step of targeted behaviors through behavioral observation, reinforcement, or prompting.Socially significant improvement in human behavior

Services are part of ABA-based behavioral treatment.

Group therapy

Group therapy must meet ALL of the following modality requirements.

Group therapy: When included in an approved behavior treatment plan, adaptive behavior treatment social-skills group services are face-to-face, involve two or more patients, and include recipients with similar diagnoses, behaviors, and treatment needs. Registered line technician group adaptive behavior treatment follows the same face-to-face and patient-similarity requirements.Two or more patients

Services may be administered by a physician, qualified health care professional, or registered line technician as specified.

ABA-derived therapy services

ServiceABA-derived therapy services

Maximum authorization period180 days per prior authorization period

Reimbursement conditionServices must be authorized by Medicaid or its designee

SCABA follow-up assessment

Code0360T TF

ServiceSCABA follow-up assessment, first 30 minutes

LimitOne unit every six months

Additional SCABA follow-up assessment

Code3061T

ServiceSCABA additional 30-minute follow-up assessment

LimitSeven units every six months; more if medically necessary

Additional LBA supervision

ServiceAdditional LBA supervision

Weekly limitOne unit per week unless otherwise clinically indicated

Maximum percentage10 percent of approved weekly therapy units

Group adaptive behavior treatment

Code0366T

ServiceGroup adaptive behavior treatment, first 30 minutes

Daily limitOne unit per day