CurrentHighmark Blueshield NenyPolicy N/A

Outpatient ABA Authorization / Request Form

This document is an authorization/request form for outpatient Applied Behavior Analysis (ABA) services used by providers to request initial or continued authorizations from Highmark BlueShield NE/NY; it affects providers, billing staff, and the member's care team submitting ABA service requests.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient ABA Authorization / Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the ABA request form with required supplemental documents (behavioral support/treatment plan, diagnostic evaluation) and indicate Initial or Continued Stay with start date.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15 mins/unitstandard unit length for listed ABA services

180 daystimeframe indicated for assessments and services

1-877-650-6112fax number for submission

Not eligibleFEP school POS

Authorization & Documentation Requirements

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Authorization and documentation criteria

Authorization requires a completed ABA request form plus the supplemental documentation and timing rules listed below:

Completed ABA authorization request form indicating Initial or Continued Stay and Start Date of Plan of Care

Full Behavioral Support Plan/Treatment Plan including the symptoms/behaviors requiring treatment (as indicated by the assessment tool) and desired outcomes described in specific, behavioral and measurable terms

Attach standardized assessment tool used

Diagnostic evaluation/report

ALL of the following

Information older than 30 days will not be accepted for continued stay review
Plan of care is subject to a 6 month (180 day / 26 week) timeframe unless otherwise noted

ALL of the following

School Place of Service is not an approved/eligible POS for FEP policies

ALL of the following

Services use 15-minute units as recorded on the form

ABA Service Codes, Unit Length, and Review Timeframe

ABA and related behavioral health 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)

1–10 of 13

1/2

Unit length / review timeframe

Standard billing unit15 minutes per unit

Review/timeframe for assessments and services180 days (26 weeks)

Unit applicationAll listed ABA and related behavioral health services use 15‑minute units as indicated on the form

How to Submit an ABA Authorization Request

Note

Submit ABA authorization request

Complete the Outpatient Behavioral Health (BH) ABA Request Form and fax it with the required supplemental documents: a full Behavioral Support/Treatment Plan and the diagnostic evaluation/report. Indicate whether the request is Initial or Continued Stay and provide the Start Date of the Plan of Care. Send the completed form and supporting documents to Fax: 1-877-650-6112. Note that the plan of care is subject to a 6-month timeframe unless otherwise noted and that Place of Service - School is not an approved/eligible POS for Federal Employee Program (FEP) policies.

Include full Behavioral Support Plan/Treatment Plan (symptoms/behaviors and measurable desired outcomes).
Include diagnostic evaluation/report.
Mark Initial or Continued Stay and enter Start Date of Plan of Care.
Fax completed form and supplemental documents to 1-877-650-6112.
Information older than 30 days will not be accepted for continued stay review (per form instructions).
School Place of Service is not eligible for FEP.

Definitions and Form Terminology

Behavioral Support Plan

DefinitionFull Behavioral Support Plan/Treatment Plan including the symptoms/behaviors requiring treatment as indicated by the assessment tool

Required contentDescribe desired outcomes/alleviation of problems and/or symptoms in specific, behavioral and measurable terms

Supplemental documentsDiagnostic evaluation/report should be attached with the plan

Authorization Request (Initial/Continued)

Authorization typeRequester must indicate Initial or Continued Stay on the form

Plan of care timeframe guidancePlan of care is subject to a 6 month (approximately) timeframe unless otherwise noted

Documentation timing rule for continued stayInformation older than 30 days will not be accepted for continued stay review

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient ABA Authorization / Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the ABA request form with required supplemental documents (behavioral support/treatment plan, diagnostic evaluation) and indicate Initial or Continued Stay with start date.

SourceLink

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