CurrentHighmark Blueshield NenyPolicy N/A

Outpatient Behavioral Health ABA Request Form Coverage Criteria

This document is an authorization/request form used by providers to request initial or continued outpatient Applied Behavior Analysis (ABA) services for members; it collects diagnostic, provider, clinical, assessment, and billing information required for authorization processing.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Behavioral Health ABA Request Form Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed ABA Request Form with a full Behavioral Support Plan/Treatment Plan and diagnostic evaluation via fax for prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

97151-97158, 0362T, 0373TCPT/HCPCS codes listed on form

15 mins/unitUnit duration

180 daysAssessment timeframe

Fax: 1-833-581-1867Submission fax

30 daysRecency req.

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Coverage and Administrative Requirements

Administrative coverage criteria

Covered when the following administrative conditions are met

Form and documentation: Completed ABA Request Form fields for member, provider and clinical information are submitted with a full Behavioral Support Plan/Treatment Plan and diagnostic evaluation/report.

Form requires listing of symptoms, desired measurable outcomes, and treatment plan.

Recency: Information and assessment reports for continued stay must be no older than 30 days.<=30 days

Information older than 30 days will not be accepted for continued stay review.

Plan of care timeframe: Plan of care is subject to a 6-month timeframe unless otherwise noted.6 months

The form specifies that Place of Service - School is not an approved/eligible POS for Federal Employee Program (FEP) policies. Providers submitting authorization requests under FEP should not bill or indicate the school POS on this ABA Request Form.

Codes, Units, and Timeframes

ABA assessment and treatment CPT codes (group 1)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

ABA assessment and treatment CPT/HCPCS codes (group 2)mixedCovered

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)

inv-05: Unit duration — 15 mins/unit

Unit duration15 mins per unit (15-minute increments)

Applicable servicesAll ABA CPT/HCPCS codes listed on the form use 15-minute units (e.g., 97151–97158, 0362T, 0373T)

Billing notationUnits are entered as number of 15-minute increments on the request form

inv-06: Assessment/Service timeframe field — 180 days / 26 weeks

Assessment/service timeframe field180 days / 26 weeks (timeframe field present for each assessment/service on the form)

Applies toBehavior Identification Assessment, Observational Follow‑Up, Adaptive Behavior Treatment codes, Exposure assessments/treatments

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required for both initial and continued ABA requests. Submit requests via this ABA Request Form. The plan of care timeframe is typically 6 months unless otherwise noted.

Prior authorization required for Initial and Continued Stay requests
Plan of care timeframe: typically 6 months (unless otherwise noted)
Place of Service: School is not an approved/eligible POS for Federal Employee Program (FEP) policies

Documentation Required

Required Supporting Documents

Attach the following supporting documents with the request. Incomplete submissions or missing documents may delay review or result in denial.

Full Behavioral Support Plan / Treatment Plan that includes the specific symptoms/behaviors requiring treatment (as indicated by the assessment tool)

Background and Intent

This ABA Request Form is designed to support authorization for outpatient Applied Behavior Analysis services for behavioral health conditions commonly addressed with ABA. It prompts providers to document presenting target behaviors (for example: self-injurious behavior, aggression, elopement, communication and social skill deficits, tantrums, and self-stimulatory behavior), complete relevant assessment fields, and attach supporting reports and a full Behavioral Support Plan/Treatment Plan.

The form explicitly captures whether the request is an Initial or Continued Stay authorization and requires a Start Date of Plan of Care. The plan of care is ordinarily subject to a 6-month timeframe unless otherwise noted, and documentation submitted for continued stay review must meet recency requirements (see documentation guidance).

Providers must complete member and provider identification sections, list primary and additional diagnoses, indicate the standardized assessment tool used, and attach the diagnostic evaluation/report and full treatment plan to support medical necessity and authorization processing.

Form Clinical Definitions

inv-13: ABA target behaviors — Clinical symptoms/mental status selections on the form include self-injurious behavior, destructive behavior, aggressive behavior, elopem...

Defined target behaviorsSelf-injurious behavior; Destructive behavior; Aggressive behavior; Elopement; Self-stimulatory behavior; Poor communication skills; Poor social skills; Verbal outbursts; Tantrum behavior; Poor general development skills; Other

Form usageProvider should check all clinical symptoms/mental status items that apply on the clinical checklist

PurposeUse checklist to document presenting behaviors that justify ABA assessment and treatment

Level of Care — Outpatient

Assessment and Treatment Requirements for ABA

ABA service supporting criteria

Form captures presenting behaviors and requires an assessment and treatment plan to justify ABA services.

Target behaviors: Presence of one or more target behaviors listed on the clinical checklist (e.g., self-injurious behavior, aggression, elopement, poor communication/social skills, tantrums, self-stimulatory behavior).

Provider should check all that apply on the form.

Assessment requirement: Behavior Identification Assessment (CPT 97151) or other specified assessments must be documented and attached.

Standardized assessment tool field present on form.

Treatment plan requirement: Full Behavioral Support Plan/Treatment Plan with measurable outcomes must be attached to support authorization request.

Information older than 30 days will not be accepted for continued stay review.

Approved Treatment Modalities

ABA

Assessment and treatment codes: Services include Behavior Identification Assessment (97151), Observational Follow-Up (97152), Adaptive Behavior Treatment (97153, 97154, 97155), Family/Multiple-Family Guidance (97156, 97157), Social Skills Group (97158), Exposure assessments/treatment (0362T, 0373T).

15 minutes per unit as listed on form.

Units and Authorization Periods

inv-17: All listed ABA CPT/HCPCS services — Units defined in 15-minute increments

Unit increment for listed servicesAll ABA CPT/HCPCS services on the form are measured in 15-minute increments

Examples of servicesBehavior Identification Assessment (97151), Observational Follow-Up (97152), Adaptive Behavior Treatment (97153–97155), Family/Multiple-Family Guidance (97156–97157), Social Skills Group (97158), Exposure services (0362T, 0373T)

Form entryUnits field on form corresponds to number of 15-minute units per service

inv-18: Authorization period — Plan of care timeframe

Authorization period (plan of care)Plan of care timeframe is subject to a 6-month timeframe unless otherwise noted

Applies toInitial and continued stay requests submitted via the ABA Request Form