CurrentMass General Brigham Health PlanPolicy N/A

Early Intensive Behavioral Intervention (EIBI) coverage criteria

This policy governs coverage, provider requirements, billing, and authorization for Early Intensive Behavioral Intervention (EIBI) for eligible members from birth up to age 3 enrolled in Mass General Brigham commercial plans or the MGB ACO; providers must be Massachusetts DPH-approved.

Policy Summary

PayerMass General Brigham Health Plan

PolicyEarly Intensive Behavioral Intervention (EIBI) coverage criteria

Policy CodePolicy N/A

Change TypeDefinition and routing updates

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests and claims to Mass General Brigham Health Plan for dates of service through 06/30/2026 and to Optum Behavioral Health for dates of service on or after 07/01/2026.

SourceLink

POLICY UPDATE CHANGES

Revised EIBI definition, added Down syndrome definition and ICD-10 codes, updated member

Prior Authorization submission routing will change to Optum Behavioral Health for dates of service on/after July 1, 2026

birth–3eligible member age range

DPH-requiredprovider approval requirement

ASD & Downdiagnoses accepted

07/01/2026

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Coverage Criteria for EIBI

Initial EIBI Coverage Criteria

Covered when ALL of the following are met

Eligibility and diagnosis: Member is enrolled in a Mass General Brigham commercial plan or MGB ACO; age from birth to 3 years; diagnosis of Autism Spectrum Disorder or Down syndrome made by a physician, psychologist, psychiatrist, APRN, or PA experienced in the diagnosis

Documentation must support behaviors attributable to the diagnosis and the IFSP must support EIBI

Program involvement: Member is actively involved in an Early Intervention program

IFSP must support EIBI treatment

Provider qualifications: EIBI services must be provided by Massachusetts DPH‑approved Specialty Service Providers; medically necessary services must be provided by or supervised by a Board‑Certified Behavior Analyst (BCBA)

Providers and staff must be DPH‑approved prior to billing

Mass General Brigham Health Plan does not reimburse services that fall outside the defined scope of Early Intensive Behavioral Intervention (EIBI). Excluded items include ASD research-based programs, experimental treatments, or use of tools not approved by the Massachusetts Department of Public Health (MDPH). Educational services such as tutoring or home schooling and recreational services not described or included within the scope of EIBI or Specialty Service Provider (SSP) services are also excluded. Additionally, visits not conducted by MDPH-approved providers, services reported with an ‘unassigned’ place of service code, unauthorized services that require authorization under this policy, and fees associated with missed appointments are not reimbursed.

Services delivered by providers who are not approved by the Massachusetts Department of Public Health (MDPH) are not reimbursed under this policy. Claims for services reported with an ‘unassigned’ place of service code will not be paid. The plan also does not reimburse for services that are experimental or not approved by MDPH. Providers should ensure they are MDPH-approved and use the correct place-of-service coding to avoid claim denials.

Coding and Eligibility

Covered CPT/HCPCS Codes for EIBImixedCovered

97151	Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes; includes face-to-face with patient/guardian, non-face-to-face analysis, scoring/interpreting, preparing report/treatment plan.
97153	Adaptive behavior treatment by protocol, administered by technician under direction of physician or other qualified health care professional, face-to-face with one patient, each 15 minutes.
97155	Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes.
97156	Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes.
97157	Multiple-family group adaptive behavior treatment guidance, administered by a qualified health care professional, face-to-face with multiple sets of guardians/caregivers, each 15 minutes.
H0031-U2	Mental health assessment by physician or other qualified health professional (U2 modifier noted in document).

Covered ICD-10 Codes - Autism SpectrumICD-10Covered

F84.5	Asperger's Syndrome
F84.8	Other pervasive developmental disorders
F84.0	Autistic disorder
F84.3	Other childhood disintegrative disorder
F84.9	Pervasive developmental disorder, unspecified
F84.2	Rett's Syndrome

Covered ICD-10 Codes - Down syndromeICD-10Covered

Q90.0	Trisomy 21 Nonmosaicism Meiotic Nondisjunction
Q90.1	Trisomy 21 Nonmosaicism Mitotic Nondisjunction
Q90.2	Trisomy 21 Translocation
Q90.9	Down syndrome, Unspecified

inv-07: Age limit — Member must be from birth up to age 3

Age rangeMember must be from birth up to age 3

Plan applicabilityApplies to Mass General Brigham commercial plans and MGB ACO members

Documentation of eligibilityMember must be actively involved in an Early Intervention program and IFSP must support EIBI treatment

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for EIBI services. For dates of service on or before 06/30/2026, submit Prior Authorization requests and claims to Mass General Brigham Health Plan. For dates of service on or after 07/01/2026, Prior Authorization requests and claims must be submitted to Optum Behavioral Health. See Prior Authorization Guidelines and Provider Resources for submission details and any date-based changes.

Prior Authorization required: submit to MGBHP for DOS on or before 06/30/2026; submit to Optum Behavioral Health for DOS on or after 07/01/2026.
Claims submission: submit claims to MGBHP for DOS on or before 06/30/2026; submit to Optum Behavioral Health for DOS on or after 07/01/2026.

Documentation Required

Required Clinical Documentation and Diagnosis

Ensure documentation includes the qualifying diagnosis and that the diagnosis is made by an authorized clinician (physician, psychologist, psychiatrist, APRN, or physician assistant experienced in diagnosing autism or Down syndrome). Claims must include the appropriate primary ICD-10 diagnosis code based on clinical determination. Maintain IFSP documentation supporting EIBI treatment and behavioral documentation attributable to Autism Spectrum Disorder or Down syndrome.

Key Definitions

inv-13: Early Intensive Behavioral Intervention (EIBI) — definition and included services

DefinitionEIBI provides behavioral assessments; interpretation of behavior analytic data; development of a highly specific treatment plan; supervision and coordination of interventions; and training other interveners to address objectives or performance goals to treat challenging behaviors that interfere with functioning.

Team compositionDelivered by a team that includes an Applied Behavior Analyst and behavior technician/paraprofessional; may be delivered by one or more qualified professional and paraprofessional staff.

Service scopeIncludes both professional (BCBA/Applied Behavior Analyst) and technician-delivered interventions and supervision of interventions.

inv-14: Autism Spectrum Disorder (ASD) — definition

Core featuresAutism Spectrum Disorder (ASD) is a developmental disorder with challenges in social communication, restricted interests, and repetitive behaviors that impair functioning; symptoms generally appear within the first two years of life.

Level of Care / Service Setting

Outpatient/Early Intervention (EIBI) — level-of-care criteria

Admission: Child under age 3 with qualifying diagnosis (Autism Spectrum Disorder or Down syndrome), actively involved in Early Intervention, and IFSP supports EIBI

Diagnosis must be made by physician, psychologist, psychiatrist, APRN, or PA experienced in autism or Down syndrome

Continued stay: Ongoing documentation of clinical benefit from services, continued IFSP support for EIBI, and services delivered by DPH‑approved providers under BCBA supervision

Clinical documentation must continue to support behaviors attributable to the diagnosis

ABA Staffing and Credentialing Criteria

ABA/Behavioral staffing and credential criteria

Provider credentialing: All EIBI providers (Specialty Service Providers) and their staff must be approved by the Massachusetts Department of Public Health prior to billing

Medically necessary services must be provided by or supervised by a Board‑Certified Behavior Analyst (BCBA)

Team composition: EIBI must be delivered by a team that includes an Applied Behavior Analyst (e.g., BCBA) and behavior technician/paraprofessional; team members must be DPH‑approved

Services billed only when provided by appropriately credentialed DPH‑approved staff

EIBI / ABA Services Provided

EIBI / ABA services — service modality criteria

Modalities: Behavior identification assessment (97151); technician‑delivered adaptive behavior treatment (97153); clinician adaptive behavior treatment with protocol modification (97155); family adaptive behavior treatment guidance (97156); multiple‑family group guidance (97157); mental health assessment (H0031‑U2)

Providers must bill the appropriate CPT/HCPCS code and modifiers as required

Visit Limits and Billing Notes

inv-20: When 2 or more specialty services are provided on same date, list each on separate lines with units and appropriate servicing provider type modifier

Billing multiple services same dayWhen 2 or more specialty services are provided on the same date of service, list each service on separate lines with the number of units for each service provided and include the appropriate servicing provider type modifier.

Unit reportingReport the number of units for each service separately on its own line item.

Modifier useInclude the servicing provider type modifier to denote the professional level or qualification rendering each service where applicable.

Background

Early Intensive Behavioral Intervention (EIBI) is provided to children participating in Early Intervention who have a diagnosis of Autism Spectrum Disorder or Down syndrome and focuses on behavioral assessment, individualized treatment planning, supervision/coordination of interventions, and training of interveners. Services outside the clinical scope of EIBI — including experimental programs or non‑MDPH‑approved approaches — are specifically not reimbursed per the plan exclusions.