CurrentHighmark Blueshield NenyPolicy N/A

Outpatient Behavioral Health (BH) - ABA Request Form

A provider-submitted authorization/request form for outpatient Applied Behavior Analysis (ABA) services describing member, provider, clinical, assessment, and requested service CPT codes/units and documentation requirements for initial and continued stay review. It governs submission content to Highmark Blueshield Neny for authorization processing.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Behavioral Health (BH) - ABA Request Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material change)

Effective Date

Next Review Date

Key ActionProviders must complete and fax the ABA Request Form with required attachments (behavioral support/treatment plan, diagnostic evaluation, standardized assessment) to 1-833-581-1867 to request initial or continued ABA authorization.

POLICY UPDATE CHANGES

No material clinical/coverage changes — form is an administrative submission and remains informational only.

10ABA CPT/HCPCS lines on form

30 daysDocumentation recency (continued stay)

6 monthsDefault plan-of-care timeframe

Policy overview

This is the Highmark BlueShield NE/NY Outpatient Behavioral Health ABA Request Form used to collect standardized clinical and administrative data to evaluate authorization requests for outpatient Applied Behavior Analysis (ABA) services. The form gathers member identifying information, diagnostic information, provider details, clinical symptom checkboxes, current medications and recent related treatment, and assessment/treatment documentation requirements.

Authorization request and documentation requirements

Authorization Request / Documentation Requirements

Form requires the following information and attachments to request initial or continued ABA services:

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title': 'Authorization Request / Documentation Requirements

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Documentation Required

Attach Required Documentation

Attach the full Behavioral Support Plan/Treatment Plan (with measurable outcomes), the standardized assessment tool result, and the diagnostic evaluation; note that documentation for continued stay review must be dated within 30 days.

Full Behavioral Support Plan/Treatment Plan with measurable behavioral outcomes
Standardized assessment tool result
Diagnostic evaluation/report
Continued stay documentation must be within 30 days

Prior Authorization

Submit Authorization Request

Complete and fax the ABA Request Form for initial or continued authorization to 1-833-581-1867.

97151
97152
97153
97154
97155
97156
97157
97158
0362T
0373T

Documentation Required

Provider signature and supervision attestation

Provider signature and license information are required; signature confirms that any paraprofessional under supervision has appropriate education and training.

CPT codes, unit definitions, and requested timeframes

The form enumerates the ABA CPT codes listed on the request form and specifies unit definitions and a recommended timeframe for each service line. Each listed service line (including but not limited to CPT codes 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, and 0373T) includes a timeframe of 180 days / 26 weeks to be specified per request.

Units are defined on the form as 15 minutes per unit for each service line (with 0373T noting the exposure protocol modification description includes the first 60 minutes).

ABA CPT Codes listed on formCPT

97151	Behavior Identification Assessment
97152	Observational Behavioral Follow-Up Assessment
97153	Adaptive Behavior Treatment by Protocol
97154	Group Adaptive Behavior Treatment w/Protocol
97155	Adaptive Behavior Treatment w/Protocol Modification
97156	Family Adaptive Behavior Treatment Guidance
97157	Multiple-Family Group Adaptive Behavior Treatment Guidance
97158	Adaptive Behavior Treatment Social Skills Group
0362T	Exposure Behavioral Follow-Up Assessment
0373T	Exposure Adaptive Behavior Treatment w/Protocol Modification (first 60 mins)

Service Line Entries and Timeframes

The form enumerates ABA CPT codes, unit definitions, and recommended timeframe (180 days / 26 weeks) to be specified per request:

Behavior Identification Assessment

Units: 15 mins/unit; CPT Code: 97151; Timeframe: 180 days/26 weeks

Observational Behavioral Follow-Up Assessment

Units: 15 mins/unit; CPT Code: 97152; Timeframe: 180 days/26 weeks

Adaptive Behavior Treatment by Protocol

Units: 15 mins/unit; CPT Code: 97153; Timeframe: 180 days/26 weeks

Group Adaptive Behavior Treatment w/Protocol

Units: 15 mins/unit; CPT Code: 97154; Timeframe: 180 days/26 weeks

Adaptive Behavior Treatment w/Protocol Modification

Units: 15 mins/unit; CPT Code: 97155; Timeframe: 180 days/26 weeks

Family Adaptive Behavior Treatment Guidance

Units: 15 mins/unit; CPT Code: 97156; Timeframe: 180 days/26 weeks

Multiple-Family Group Adaptive Behavior Treatment Guidance

Units: 15 mins/unit; CPT Code: 97157; Timeframe: 180 days/26 weeks

Adaptive Behavior Treatment Social Skills Group

Units: 15 mins/unit; CPT Code: 97158; Timeframe: 180 days/26 weeks

Exposure Behavioral Follow-Up Assessment

Units: 15 mins/unit; CPT Code: 0362T; Timeframe: 180 days/26 weeks

Exposure Adaptive Behavior Treatment w/Protocol Modification (first 60 mins)

Units: 15 mins/unit; CPT Code: 0373T; Timeframe: 180 days/26 weeks

Billing Rule

Unit Definition

Units are defined as 15 minutes per unit; the 0373T code is noted as the exposure adaptive behavior treatment with protocol modification (first 60 minutes) in the form description.

97151
97152
97153
97154
97155
97156
97157
97158
0362T
0373T

Provider responsibilities and operational notes

Operationally, this form governs the content that providers must submit to Highmark BlueShield NE/NY for ABA authorization processing. Providers must indicate whether the request is an Initial or Continued Stay, include the Start Date of the Plan of Care, and attach required documentation (behavioral support/treatment plan, diagnostic evaluation, and standardized assessment results).

The form sets an expectation that continued stay documentation be current (information must be no older than 30 days) and that the default plan-of-care timeframe authorized via the form is 6 months unless otherwise noted on the form.

Thresholds

Documentation recency for continued stay reviewInformation must be <= 30 days old

Plan of care timeframe6 months (unless otherwise noted)

Note

Plan of Care Timeframe

Plan of care is subject to a 6-month (180-day) timeframe unless otherwise noted.

OpenPayer

Outpatient Behavioral Health (BH) - ABA Request Form

Policy overview

Authorization request and documentation requirements

CPT codes, unit definitions, and requested timeframes

Provider responsibilities and operational notes

Revision history