CurrentlucetPolicy N/A

Applied Behavior Analysis (ABA) Treatment Request for Autism Spectrum Disorder

Authorization and documentation requirements for requests for Applied Behavior Analysis (ABA) services for members with Autism Spectrum Disorder, including required submissions, attestations, service locations, and provider/patient information for Lucet Health. Governs initial and ongoing authorization submissions and required supporting evaluations and attestations.

Policy Summary

Payerlucet

PolicyApplied Behavior Analysis (ABA) Treatment Request for Autism Spectrum Disorder

Policy CodePolicy N/A

Change TypeRevised form (Dec. 2024)Last Reviewed Nov. 2025

Effective Date

Next Review Date

Key ActionSubmit required evaluations (ASD-specific diagnostic within 5 years, wellness check within 1 year, cognitive/developmental within 5 years, adaptive behavioral within 6 months), and a treatment plan with baseline/current data and mastery criteria, and complete the Lucet ABA Treatment Request Form with requested start date, hours, frequency, locations, and attestations.

SourceLink

POLICY UPDATE CHANGES

Document title indicates 'Treatment Request for Applied Behavior Analysis for Autism Spectrum Disorder - Revised Dec. 2024, Last Reviewed Nov. 2025.'

8Required submission/document types listed

3State-specific additional requirements called out

Scope & Summary

This is the Lucet Health "Treatment Request for Applied Behavior Analysis for Autism Spectrum Disorder" form (Revised Dec. 2024, Last Reviewed Nov. 2025) used by the Autism Resource Program to request ABA services for members with Autism Spectrum Disorder (ASD).

Policy Summary

Payerlucet

PolicyApplied Behavior Analysis (ABA) Treatment Request for Autism Spectrum Disorder

Policy CodePolicy N/A

Change TypeRevised form (Dec. 2024)Last Reviewed Nov. 2025

Effective Date

Next Review Date

SourceLink

On This Page

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Required Submission Documentation & Attestations

Required Submission Documentation for ABA Authorization

Authorization requests must include the following documentation as applicable (items marked 'Required for initial assessment' must be provided for initial requests):

ALL of the following

Complete diagnostic evaluation including an ASD-specific standardized assessment completed by a clinician licensed and qualified to make such a diagnosis confirming member has ASD dated within past 5 years
Required for initial assessment
Wellness Check completed by the primary care physician, including a Review of Symptoms (ROS) with a neurological component, dated within the past year
If not submitted, must be submitted within first 90 days of treatment or scheduled date for appointment
Cognitive / developmental evaluation dated within past 5 years
If not submitted, must be submitted within first 90 days of treatment or scheduled date for appointment
Adaptive Behavioral Evaluation dated within past six months
If not submitted, must be submitted within first 90 days of treatment or scheduled date for appointment
State-specific additional requirements (provide within first 90 days if applicable):
- For Arkansas/Walmart policies: Speech Evaluation by a licensed speech therapist
  Provide within first 90 days if applicable
- For Arkansas/Walmart policies: Sensorimotor evaluation
  Provide within first 90 days if applicable
- For Arkansas/Walmart policies: Hearing evaluation
  Provide within first 90 days if applicable
- For State of Kansas: Speech Evaluation by a licensed speech therapist
  Provide within first 90 days if applicable
- For State of Kansas: Lead poisoning assessment
  Provide within first 90 days if applicable
Treatment plan including baseline data, current data, and mastery criteria for all goals
Attach treatment plan
Completed Treatment Request Form with member, provider, and requested service details (hours, frequency, locations), and attestations

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Attestations Required on Submission

All of the following attestations must be checked/confirmed by provider:

ALL of the following

Treatment goals and clinical documentation are focused on active core deficits of ASD (social communication, social interaction, restricted/repetitive behaviors)
ABA treatment is not a substitute for academic, medical or other behavioral health services
Treatment setting and intensity (comprehensive vs focused) is appropriate for member's clinical needs
All services provided in manner consistent with Lucet Provider Manual, BACB Ethics Code or relevant ethics code, standards of care, and state laws
Provider is accounting for generalization of skills, caregiver involvement or alternative plan, coordination of care, and transition/discharge planning; info is individualized, measurable, and attainable

Service Logistics / Authorization Details

Provider must supply requested scheduling and location information and attest to verifications:

ALL of the following

Requested treatment start date and requested hours, frequency (weekly/monthly/per authorization) must be provided
Location(s) of services must be specified (Clinic, Home, School, Telehealth, Community, Other)
Provider must attest verification of benefit coverage for proposed places of service
Provider must attest they will follow guidelines regarding concurrent billing from local Blue
Provider must attest they will utilize the hours requested and that hours reflect availability of member, caregiver, provider, and line therapists

Form Completion Risks

Consequences of inadequate submission:

ALL of the following

Illegibility may result in delay in authorization
Omissions and generalities could result in peer review or denial due to lack of information

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What Providers Must Do

Documentation Required

Submit required evaluations and treatment plan

Providers must attach required evaluations and a treatment plan when requesting ABA authorization. These include ASD diagnostic confirmation and recent functional assessments plus a treatment plan documenting baseline/current data and mastery criteria.

ASD-specific diagnostic evaluation including a standardized assessment by a qualified/licensed clinician confirming ASD dated within the past 5 years (required for initial assessment).
Wellness check completed by the primary care physician, including a Review of Symptoms (ROS) with a neurological component, dated within the past year (if not submitted, must be provided within first 90 days of treatment or scheduled appointment).
Cognitive / developmental evaluation dated within the past 5 years (if not submitted, must be provided within first 90 days).
Adaptive behavioral evaluation dated within the past 6 months (if not submitted, must be provided within first 90 days).
Treatment plan with baseline data, current data, and mastery criteria for all goals (attach to request).
State-specific evaluations (when applicable) to be provided within first 90 days: for Arkansas/Walmart — speech evaluation by licensed speech therapist, sensorimotor evaluation, hearing evaluation; for Kansas — speech evaluation, lead poisoning assessment, hearing evaluation.

Prior Authorization

Authorization request completion and attestations

Complete and submit the Lucet ABA Treatment Request Form with all requested service and provider information and required attestations; incomplete or unclear submissions can delay authorization or result in denial.

Complete the Lucet ABA Treatment Request Form with requested treatment start date, requested hours and frequency (weekly/monthly/per authorization).
Specify location(s) of services (Clinic, Home, School, Telehealth, Community, Other).
Include provider attestations and signatures as indicated on the form.
Provide all requested provider and member details and treatment logistics; missing or unclear information may delay review or lead to denial.

Documentation Required

Guardian/authorized delegate documentation for adults

If the member is age 18 or older, submit guardianship paperwork or authorized delegate documentation with the request.

Submit guardianship paperwork for members age 18+ along with the authorization request.

Billing Rule

Verify benefit coverage and concurrent billing rules

Providers must verify member benefit coverage for each proposed place of service and attest they will follow local Blue concurrent billing guidelines when submitting the authorization request.

Verify benefit coverage for the proposed places of service and attest to that verification on the form.
Attest that you will follow guidelines regarding concurrent billing from your local Blue.

Background & Definitions

This ABA treatment request form is used by Lucet Health's Autism Resource Program to collect member, provider, authorization, treatment plan, and attestations information necessary for authorization of ABA services for members with ASD. It includes member and provider contact details, requested treatment start date, hours and frequency, locations of service, and attestations regarding benefit verification and billing.

The form requires submission of diagnostic and evaluation documents with specific timelines: an ASD-specific diagnostic evaluation dated within the past 5 years, a Wellness Check with ROS dated within the past 1 year (or submitted within the first 90 days if not included at initial request), a cognitive/developmental evaluation dated within 5 years (or within 90 days if not included), and an adaptive behavioral evaluation dated within 6 months (or within 90 days if not included). It also lists state-specific additional requirements (e.g., speech, sensorimotor, hearing, and lead assessments) that must be provided within the first 90 days when applicable.

Definitions:

IEP: Individualized Education Program — the form asks whether the member attends school and whether the member has an IEP.

OpenPayer

Applied Behavior Analysis (ABA) Treatment Request for Autism Spectrum Disorder

Scope & Summary

Required Submission Documentation & Attestations

What Providers Must Do

Codes

Background & Definitions

Document Changes