CurrentHighmark Blueshield NenyPolicy N/A

Outpatient ABA Request/Authorization Form

This document is an outpatient behavioral health Applied Behavior Analysis (ABA) request form used to collect clinical, diagnostic, provider, and billing information for prior authorization and continued stay requests for ABA services under Highmark BlueShield NENY. It affects providers submitting ABA authorization requests and the payer's utilization management staff.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient ABA Request/Authorization Form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed ABA authorization and required attachments via fax to 1-833-581-1867.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15 minsUnit duration

97151-97158, 0362T, 0373TCodes on form

180 daysTimeframe field

1-833-581-1867Fax submission

Authorization and Documentation Requirements

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inv-01: Authorization documentation and service line requirements

Required documentation and treatment details to accompany an initial or continued-stay authorization request for outpatient ABA services.

Attach full Behavioral Support Plan/Treatment Plan including the symptoms/behaviors requiring treatment and measurable desired outcomes

Refer to Assessment and Treatment section for required elements.

Attach diagnostic evaluation/report

A diagnostic report must accompany the request.

Indicate the standardized assessment tool used; information older than 30 days will not be accepted for continued stay review

Assessments must be current (<=30 days) for continued stay review.

Specify whether the request is Initial or Continued Stay and provide the Start Date of the Plan of Care

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

For each ABA service line, list CPT/HCPCS code, units (15 mins/unit), timeframe (180 days / 26 weeks), and place of service

Complete service-line details are required on the form for utilization review.

Include provider signature, license information, and supervision attestation for paraprofessionals when applicable

Provider attestation confirms supervision and credentials.

Submit the completed form and all supplemental documents via fax to 1-833-581-1867

Incomplete or illegible forms may delay processing.

Billing Codes, Units, and Timeframes

ABA-related CPT/HCPCS codesmixed

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)

ABA-related CPT/HCPCS codes (duplicate listing from form)mixed

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)

Unit duration — 15 mins/unit

Unit duration15 mins/unit

Billing conversionEach service line lists units and corresponds to 15-minute billing units

Applies to codesStandard unit duration is used for CPT/HCPCS codes 97151-97158, 0362T, 0373T as listed on the form

Default timeframe field — 180 days / 26 weeks

Default timeframe180 days / 26 weeks

Form usageTimeframe field provided for each ABA service line to indicate authorization period

Continued stay relevanceTimeframe aligns with typical authorization/continued stay reporting on the form

Prior Authorization Request Form & Submission

Prior Authorization

Prior Authorization Required

Prior authorization request form for Applied Behavior Analysis (ABA) services. Use this form to request initial authorization or continued stay authorization for outpatient ABA services. Complete all provider, diagnostic, clinical, assessment and billing fields and attach required supporting documents. Send faxed form and supplemental documents to 1-833-581-1867. Please print clearly — incomplete or illegible forms may delay processing.

Provider action: Submit the Prior Authorization Request Form for ABA services for both Initial and Continued Stay requests.
Form options: Initial or Continued Stay — indicate by checking the appropriate box.
For Continued Stay requests: include Start Date of Plan of Care. Note: plan of care is subject to a 6-month timeframe unless otherwise noted.
Attach required documentation: full Behavioral Support Plan / Treatment Plan including symptoms/behaviors identified by standardized assessment tool; description of desired outcomes in specific, behavioral, measurable terms; diagnostic evaluation/report.
Documentation note: Information older than 30 days will not be accepted for continued stay review.
Place of Service: School is not an approved/eligible POS for Federal Employee Program (FEP) policies.

Key Terms and Clinical Checklists

Plan of care

DefinitionPlan of care is the documented ABA treatment plan required with authorization requests

Attachments requiredAttach full Behavioral Support Plan/Treatment Plan including symptoms/behaviors and measurable desired outcomes

Authorization timeframePlan of care is typically subject to a 6-month timeframe for authorization/continued stay unless otherwise noted

Start dateAuthorization requests must indicate Start Date of Plan of Care on the form

Clinical symptom checklist

PurposeChecklist documents patient symptoms/behaviors to inform treatment planning

Example behaviors (selected items)Self-injurious behavior; Elopement; Poor communication skills; Poor social skills; Aggressive behavior; Tantrum behavior

Use with assessmentsChecklist complements standardized assessment tool and behavioral support plan attachments