Autism Spectrum Disorders — ABA authorization form and billing guidance
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This document governs authorization, required documentation, and billing codes for Applied Behavior Analysis (ABA) services for members covered by Highmark West Virginia. It affects providers submitting ABA requests and authorizations for members.
No material clinical or coverage changes in this revision.
Coverage and Authorization Criteria
ABA coverage criteria
Covered when ALL of the following documentation and authorization requirements are met:
ALL of the following
- Submit documentation of an ASD diagnosis and diagnostic evaluation/report (diagnostic information older than 90 days will not be accepted for concurrent review).
- Provide a full Behavioral Support Plan/Treatment Plan that includes: the symptoms/behaviors requiring treatment; desired outcomes described in specific, behavioral, and measurable terms; documentation of the clinical team providing care including signature(s) of licensed supervising provider(s); and the location (place of service) where services are provided.
- Authorizations of care are subject to a standard 6-month timeframe (unless otherwise noted); Delaware member policies may be authorized for up to 12 months.
- ABA services that are primarily for educational purposes will not be authorized; services provided in the school setting are not eligible under the Federal Employee Program (FEP).
Authorization submission notes
- Submit the completed authorization form and supplemental documentation (diagnosis, treatment plan, signatures, location) as required by the payer's submission process.
- Concurrent review will not accept diagnostic information older than 90 days.
Limitations/Exclusions
- ABA services primarily for educational purposes will not be authorized.
- Services provided in the school setting are not eligible for FEP policies.
Coding and unitization
- Behavior Identification Assessment (CPT 97151) and other listed ABA procedure codes must be billed in 15-minute units.
ALL of the following
- Authorizations are subject to the payer's medical policy (Highmark policy V-37 Autism Spectrum Disorders).
Procedure Codes and Billing Units
| 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 |
| 0373T | Exposure Adaptive Behavior Treatment with Protocol Modification (first 60 mins) |
Authorization Submission & Provider Requirements
Authorization submission requirements and limitations
Submit an authorization request (initial or continued stay) with a completed authorization form and attach documentation of ASD diagnosis, a full Behavioral Support/Treatment Plan (including symptoms/behaviors requiring treatment, documentation of clinical team with signatures of licensed supervising provider(s), and location of services), and the diagnostic evaluation/report. Note that information older than 90 days will not be accepted for concurrent review. Authorizations of care are generally subject to a 6-month timeframe (12 months for Delaware member policies). ABA services primarily for educational purposes or services provided in the school (for FEP) will not be authorized.
- Include desired outcomes described in specific, behavioral, and measurable terms.
- Ensure signatures of licensed supervising provider(s) are included on the Behavioral Support/Treatment Plan.
- Concurrent review will not accept diagnostic information older than 90 days.
- Authorizations generally cover 6 months; Delaware member policies: 12 months.
Submission channel
Fax the completed form and all supplemental documents to 1-877-650-6112. Incomplete or illegible forms may delay processing.
- Print clearly to avoid processing delays.
Key Definitions
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