CurrentHighmark Blueshield NenyPolicy N/A

Outpatient ABA (Applied Behavior Analysis) authorization request form

This document is a provider-facing authorization and continued stay request form for outpatient behavioral health ABA services for Highmark BlueShield NE/NY members; it collects diagnostic, provider, clinical, and service coding/timeframe details to support prior authorization decisions.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient ABA (Applied Behavior Analysis) authorization request form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with diagnostic evaluation, full behavioral support/treatment plan, specified CPT codes and units (15-minute increments), and plan-of-care start date.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15 minsbilling unit duration

180 daysdefault timeframe

97151-97158, 0362T, 0373Tlisted codes

Faxsubmission channel

Coverage Criteria and Submission Requirements

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Authorization request requirements

Covered when the provider submits an authorization request meeting the following

Authorization type and plan of care: Request marked as Initial or Continued Stay and includes start date of plan of care; plan of care is subject to a 6-month timeframe unless otherwise noted6 months

Place of Service: School is not an approved/eligible POS for Federal Employee Program (FEP) policies

For Federal Employee Program (FEP) members, Place of Service: School is explicitly not an approved/eligible POS. Do not submit authorization requests indicating school as the place of service for FEP policies.

For continued stay reviews, the policy requires timely documentation: information older than 30 days will not be accepted. Failure to provide required documentation within this 30-day window may result in denial of the continued stay request.

Procedure Codes, Units, and Timeframes

Listed ABA CPT/CPT-analog codesCPT

97151	Behavior Identification Assessment
97152	Observational Behavioral Follow-Up Assessment
97153	Adaptive Behavior Treatment by Protocol
97154	Group Adaptive Behavior Treatment with Protocol
97155	Adaptive Behavior Treatment with 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 (temporary code)
0373T	Exposure Adaptive Behavior Treatment with Protocol Modification (first 60 mins) (temporary code)

inv-05: Unit duration — 15 mins/unit

Unit duration15 mins/unit

Billing incrementUnits reported in 15-minute increments for all listed ABA assessment and treatment codes

Applies to assessmentsBehavior Identification Assessment (97151) and Observational Behavioral Follow-Up Assessment (97152) use 15-min units

Applies to treatmentAdaptive Behavior Treatment codes (97153-97158, 0362T, 0373T) billed in 15-min units

inv-06: Default timeframe for plan of care — 180 days / 26 weeks

Default plan-of-care timeframe180 days / 26 weeks

Assessment timeframeBehavior Identification and Observational Follow-Up listed with 180 days / 26 weeks timeframe

Treatment timeframeTreatment codes also reference a default 180 days / 26 weeks timeframe unless otherwise noted

What the Provider Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required for initial and continued outpatient Applied Behavior Analysis (ABA) services. Prior authorization requests must be submitted for the services and CPT/CPT‑analog codes listed on the ABA request form (examples include 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T). Include units and requested timeframe (units = 15 minutes/unit) and indicate Place of Service. Requests for school POS are not eligible under Federal Employee Program (FEP) policies.

Submit prior authorization for both Initial and Continued Stay requests
List CPT/CPT-analog codes and units (15 minutes per unit) on the request
Indicate start date and timeframe (plan of care typically approved in 6‑month intervals)
Do not request school POS for FEP members

Documentation Required

Required Supporting Clinical Documents

Attach the full Behavioral Support Plan / Treatment Plan with the authorization request. The plan must describe the symptoms/behaviors requiring treatment as identified by the assessment tool and state desired outcomes in specific, behavioral, and measurable terms. Also include the diagnostic evaluation/report and copies of any standardized assessment tools used. For continued stay reviews, documentation must be current — information older than 30 days will not be accepted.

Full Behavioral Support Plan / Treatment Plan describing target behaviors and measurable goals
Diagnostic evaluation/report
Standardized assessment tool results referenced in the form
Progress notes and documentation supporting medical necessity for continued services (must be ≤30 days old for continued stay review)

Policy Background

Applied Behavior Analysis (ABA) services address problem behaviors, communication, social, and adaptive skills—commonly for patients with autism spectrum disorder. The authorization form collects clinical details to support medical necessity, including the type of request (Initial or Continued Stay), the start date of the plan of care, and a full Behavioral Support/Treatment Plan with specified, measurable treatment goals. The form notes that a plan of care is typically subject to a 6-month (180-day) timeframe, and requires up-to-date assessment documentation (see timely documentation rule above) to support continued services.

Assessment and Treatment Service Definitions

inv-13: ABA assessment and treatment services — Behavior Identification Assessment and Observational Behavioral Follow-Up Assessment are assessment services used to evaluate behavioral ...

Behavior Identification AssessmentCPT 97151 — assessment service to evaluate behavioral targets; units in 15-minute increments; timeframe typically 180 days/26 weeks

Observational Behavioral Follow-Up AssessmentCPT 97152 — follow-up observational assessment; units in 15-minute increments; timeframe typically 180 days/26 weeks

Exposure Behavioral Follow-Up AssessmentCPT 0362T — temporary code for exposure follow-up assessment; units in 15-minute increments; timeframe typically 180 days/26 weeks

Assessment purposeUsed to evaluate behavioral targets and progress to inform the ABA plan of care

Clinical Presentation and Documentation Needed

Clinical presentation and required documentation

Clinical indications to document on form

Problem behaviors/targets: Select applicable symptoms such as self-injurious behavior, destructive behavior, aggression, elopement, poor communication, poor social skills, tantrums, self-stimulatory behavior, poor general development skills, verbal outbursts, or other

Also list current medications and prior/current treatment within past six months.

ABA Treatment Modalities

ABA

Assessment services: Behavior Identification Assessment (CPT 97151) and Observational Behavioral Follow-Up Assessment (CPT 97152) billed in 15-minute units with timeframe typically 180 days (26 weeks)180 days

Units billed in 15-minute increments

Treatment services: Adaptive Behavior Treatment by Protocol and related ABA treatment codes (CPT 97153–97158, temporary codes 0362T and 0373T) billed in 15-minute units15 mins/unit

Timeframe typically 180 days (26 weeks)

Plan of Care Timeframe and Visit Limits

inv-17: ABA plan of care — Plan of care is subject to a 6-month timeframe unless otherwise noted

Plan-of-care timeframe (standard)Plan of care is subject to a 6-month (180-day/26-week) timeframe unless otherwise noted

Requirement for start dateAuthorization requests must include the Start Date of Plan of Care

Continued stay notePlan of care timeframe governs both initial and continued stay requests unless a different timeframe is specified