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Outpatient ABA Authorization Request Form — Coverage Criteria

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This document is an outpatient behavioral health Applied Behavior Analysis (ABA) authorization request form used by providers to request initial or continued ABA services from Highmark BlueShield NENY. It affects providers submitting ABA prior authorization and supporting documentation for members in the plan.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient ABA Authorization Request Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed ABA Request Form with required clinical attachments (assessment results, full Behavioral Support Plan/Treatment Plan, diagnostic evaluation) for initial or continued authorization; information older than 30 days will not be accepted for continued review.

SourceLink

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CurrentHighmark Blueshield NenyPolicy N/A

Outpatient ABA Authorization Request Form — Coverage Criteria

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Sign up for all Highmark Blueshield Neny policy alerts

Know when Highmark Blueshield Neny releases new policies or updates existing guidance.

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Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient ABA Authorization Request Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

Coverage Criteria for ABA Services

Initial and Continued ABA service authorization criteria

Covered when documentation and form fields are completed and supporting clinical materials are attached:

Authorization prerequisites: Submit a completed ABA Request Form indicating Initial or Continued Stay; include requested CPT/HCPCS codes, provider and facility information, primary and additional diagnoses, date of diagnosis, and the symptom/behavior checklist.

Supported by chunk 5 and chunks 1-2 in the brief

Required clinical attachments: Attach standardized assessment tool results, a full Behavioral Support Plan/Treatment Plan describing symptoms requiring treatment and desired outcomes in specific, measurable behavioral terms, and the diagnostic evaluation/report.information <=30 days for continued review

Supported by chunk 4

Plan of care timeframe defaults to 6 months unless otherwise noted.6 months default

Supported by chunk 5

The ABA Request Form notes that Place of Service 'School' is not an approved/eligible POS for the Federal Employee Program (FEP). Additionally, the form includes a program-specific eligibility note that FEP and Centene policies are not eligible for certain listed codes; providers must confirm member program eligibility and submit requests consistent with those program rules.

Coding and Timeframe Details

Covered CPT Codes (ABA series)CPTCovered

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

Exposure-related codesCPTCovered

0362T	Exposure Behavioral Follow-Up Assessment
0373T	Exposure Adaptive Behavior Treatment w/Protocol Modification (first 60 mins)

HCPCS/H-s codesHCPCSCovered

H0032	Mental Health Service Plan Development by Non-Physician
H2019	Therapeutic Behavioral Services, per 15 minutes
H2021	Community-Based Around Services, per 15 minutes Wrap-E

inv-06: Assessment/service timeframe

Assessment/service timeframe180 days / 26 weeks

Plan of care default window6 months (plan of care timeframe defaults to 6 months unless otherwise noted)

Continued review recency requirementInformation older than 30 days will not be accepted for continued review

Provider Actions, Documentation, and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization required via the ABA Request Form for both initial and continued stay requests. Complete and submit the ABA Request Form; plan of care defaults to a 6-month timeframe unless otherwise noted. School/Place of Service is not an approved/eligible POS for Federal Employee Program (FEP) policies.

Authorization required for Initial and Continued Stay requests
Plan of care timeframe defaults to 6 months
School POS is not eligible for FEP

Note

FEP / Centene Code Eligibility

Federal Employee Program (FEP) and Centene policies are not eligible for certain listed ABA codes. Review coding guidance on the ABA Request Form and do not bill ineligible codes for FEP/Centene members.

FEP/Centene not eligible for specified ABA codes listed on form

Background on ABA Services

Applied Behavior Analysis (ABA) services address maladaptive behaviors and skill deficits commonly seen in developmental and behavioral disorders. Typical treatment targets captured on the form include self-injurious behavior, destructive behavior, poor social and communication skills, aggression, elopement, self-stimulatory behavior, tantrums, and delays in general adaptive development. Authorization requires documentation of these problem behaviors and recent clinical information.

Assessment and treatment planning for ABA must include a standardized assessment tool and an attached full Behavioral Support Plan/Treatment Plan that describes symptoms and specific, measurable desired outcomes. These materials support the identification of behavioral targets and the justification for the requested ABA services.

Behavioral Symptoms and Clinical Status

inv-13: Behavioral symptoms/clinical status

Provider-selected symptom checklistSelf-injurious behavior; Destructive behavior; Aggressive behavior; Elopement; Self-stimulatory behavior; Tantrum behavior; Verbal outbursts; Other

Social and communication deficitsPoor social skills; Poor communication skills; Poor general development skills (e.g., imitation, identifying objects, sharing skills)

Medication and recent treatment fieldsCurrent Medications and Previous or current treatment within the past six months are requested on the form

Level of Care — Outpatient

Outpatient

Outpatient services are authorized when the following admission and continued stay requirements are met for the outpatient level of care:

Admission (authorization) requirements: Completed ABA Request Form indicating Initial or Continued Stay, requested CPT/HCPCS codes, provider/facility information, symptom/behavior checklist, and attached clinical documentation as specified in the form.

Supported by chunk 5

Continued stay documentation: Updated plan of care (6-month default), recent assessment data and progress toward measurable outcomes, and documentation not older than 30 days for continued review must be provided.<=30 days for review; 6-month plan window

Supported by chunks 4 and 5

ABA Clinical Criteria

ABA clinical criteria

Behavioral targets and assessment requirements for ABA authorization:

Target behaviors: One or more of the listed behaviors identified as requiring treatment: self-injurious behavior; destructive behavior; poor social skills; poor general development skills (e.g., imitation, identifying objects, sharing); aggressive behavior; elopement; self-stimulatory behavior; poor communication skills; verbal outbursts; tantrum behavior; other.

Supported by chunk 3

Assessment and plan: A standardized assessment tool must be used and a full Behavioral Support Plan/Treatment Plan detailing the symptoms/behaviors requiring treatment and specific, measurable desired outcomes must be attached.

Supported by chunk 4

Assessments and ABA Therapy Modalities

ABA assessments and therapy

Assessment services: Behavior Identification Assessment (CPT 97151) and Observational Behavioral Follow-Up Assessment (CPT 97152) with timeframe and unit fields completed on the form.180 days default

Supported by chunk 6

Treatment services: Adaptive Behavior Treatment by Protocol and related codes (CPT 97153–97158), protocol modification (CPT 97155), exposure-related codes (0362T, 0373T), and applicable HCPCS (e.g., H0032, H2019, H2021) may be requested with units entered in 15-minute increments as specified on the form.15-minute unit

Supported by chunks 6 and 7

Visit Units and Limits

inv-17: Listed ABA and behavioral services (CPT/HCPCS codes)

ABA assessment codes (15-min units)97151 (Behavior Identification Assessment); 97152 (Observational Behavioral Follow-Up Assessment)

ABA treatment codes (15-min units)97153, 97154, 97155, 97156, 97157, 97158 (Adaptive behavior treatment series; group/family/social skills and protocol modification)

Exposure-related and HCPCS codes (15-min units)0362T, 0373T (exposure assessment and treatment); H0032, H2019, H2021 (HCPCS/H-codes for MH plan development and therapeutic/community-based services)