Applied Behavior Analysis (ABA) / Behavioral Health Treatment (BHT) services coverage criteria
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Defines coverage and prior authorization guidance for medically necessary Behavioral Health Treatment (BHT) services, including ABA, for eligible Kern Family Health Care members (primarily beneficiaries under 21) and guidance for providers on submitting requests.
No material clinical or coverage changes in this revision.
Coverage criteria for BHT / ABA services
Coverage for BHT / ABA services
Covered when ALL of the following are met
Extracted directly from document.
The source document does not list any explicit exclusions for Behavioral Health Treatment (BHT) or Applied Behavior Analysis (ABA) services. Coverage is described in terms of medical necessity and eligibility (see age threshold), without a named list of excluded diagnoses or services.
The document does not enumerate specific conditions that are labeled not medically necessary. However, it states that services must be supported by documentation demonstrating medical necessity; therefore, a prior authorization request may be denied if the provider does not show supporting assessment findings, symptoms, or pertinent records that justify BHT/ABA services.
Codes and eligibility
| 96116 | Used for prior authorization requests for BHT services (as stated in document) |
What providers must do
Prior authorization must use CPT 96116 and include assessment findings
Submit a prior authorization request using CPT code 96116 for members who may be eligible for BHT services; include assessment findings and pertinent medical records and specify if requesting a Comprehensive Diagnostic Evaluation (CDE) or Mental Health Assessment (MHA) when appropriate.
- Use CPT 96116 on the prior authorization request.
- Attach concerning assessment findings (symptoms and behaviors observed and those reported by parent/guardian).
- Include pertinent medical records to support medical necessity and to request a CDE or MHA if indicated.
Provider administrative actions to request BHT services
Complete administrative steps necessary to request BHT services: confirm beneficiary is under 21, obtain a licensed clinician determination of medical necessity, and submit a prior authorization with supporting assessment findings and records.
- Verify eligibility (beneficiary under 21 years of age).
- Ensure a licensed physician, surgeon, or psychologist determines BHT services are medically necessary.
- Submit prior authorization using CPT 96116 with assessment findings and pertinent medical records.
Assessment findings and records required with prior authorization
Include concerning findings from assessments—such as symptoms and behaviors observed in the member and those reported by the parent or guardian—and pertinent medical records when submitting a prior authorization request.
- Document symptoms and behaviors observed during assessment.
- Include parent/guardian-reported behaviors and concerns.
- Attach relevant medical records that support the assessment and medical necessity.
Risk of denial if medical necessity is not documented
Failure to demonstrate medical necessity—including omission of documented symptoms/behaviors and supporting assessment findings—when submitting a prior authorization may result in non-approval.
- Medical necessity must be documented by a licensed clinician and supported by assessment findings.
- Lack of pertinent assessment findings or medical records risks denial of the prior authorization.
Background on BHT / ABA
Applied Behavior Analysis (ABA) is presented as one component of Behavioral Health Treatment (BHT)medically necessary BHT services for eligible beneficiaries under 21 years of age, applied to any health condition when a licensed physician, surgeon, or psychologist determines such services are necessary. BHT encompasses ABA and a range of evidence‑based behavioral interventions intended to prevent or minimize behaviors that interfere with learning and social interaction; examples include behavioral interventions, cognitive behavioral intervention, language training, parent/guardian training, social skills packages, and other listed modalities. Providers are instructed to submit prior authorization using CPT 96116 with concerning assessment findings and pertinent medical records to support medical necessity and to request a Comprehensive Diagnostic Evaluation (CDE) or Mental Health Assessment (MHA) when appropriate.
Definitions and examples
Outpatient / BHT level-of-care criteria
ABA / BHT medical necessity criteria
ABA/BHT medical necessity criteria
Criteria for ABA/BHT are based on medical necessity determinations and supporting assessments for beneficiaries under 21.
Derived from guidance to include concerning findings with prior authorization requests.
BHT / ABA treatment modalities
BHT / ABA modalities
List of example BHT services from document.
Visit limits and related notes
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