CurrentMass General Brigham Health PlanPolicy N/A

Early Intensive Behavioral Intervention (EIBI) Policy

Defines reimbursement, billing, prior authorization, provider and membership eligibility, and coding requirements for Early Intensive Behavioral Intervention (EIBI) services for Mass General Brigham Health Plan members from birth up to age 3 who are involved in Early Intervention programs and have an Autism Spectrum Disorder diagnosis.

Policy Summary

PayerMass General Brigham Health Plan

PolicyEarly Intensive Behavioral Intervention (EIBI) Policy

Policy CodePolicy N/A

Change TypeCode update (Oct 1, 2022)Annual review (Jan 1, 2024)

Effective Date

Next Review Date

Key ActionSubmit prior authorization requests for EIBI services to Mass General Brigham Health Plan for members in MGB ACO and Commercial plans prior to billing.

SourceLink

POLICY UPDATE CHANGES

October 1, 2022 code update (added/updated CPT/HCPCS coding requirements).

January 1, 2024 annual review with no policy change.

6Listed ICD-10 covered diagnoses

10Listed CPT/HCPCS/modifier codes

15Billing minute increment (minutes)

Policy overview & scope

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This policy implements reimbursement for Early Intensive Behavioral Intervention (EIBI) consistent with Massachusetts Chapter 207 (An Act Relative to Insurance Coverage for Autism) and aligns with Massachusetts Department of Public Health (MDPH) Early Intervention standards. It covers members from birth up to 3 years of age who are involved in an Early Intervention program and have an Autism Spectrum Disorder diagnosis documented by a qualified clinician, and requires that EIBI providers (Specialty Service Providers - SSP) and staff be approved by the Massachusetts Department of Public Health prior to billing.

The policy applies to Mass General Brigham Health Plan lines including Commercial, MassHealth, and Medicare Advantage where noted and defines reimbursement, billing, prior authorization, provider and membership eligibility, and coding requirements for EIBI services for eligible members from birth up to age 3 who are involved in Early Intervention programs and have an Autism Spectrum Disorder diagnosis.

Key thresholds and dates

Policy / PayerMass General Brigham Health Plan - EIBI reimbursement policy

Age limitbirth up to 3 years

Billing unit increment15-minute increments

Required billing codes effectiveProviders required to bill listed CPT/HCPCS codes effective 10/01/2022

Prior authorizationPrior authorization required for MGB ACO and Commercial plans (must submit PA to Mass General Brigham Health Plan)

MDPH approvalEIBI/SSP providers and staff must be approved by Massachusetts Department of Public Health prior to billing

Last review2024-01-01 (annual review, no policy change)

Eligibility, medical necessity, authorizations, and exclusions

Eligibility / Medical Necessity for EIBI

Covered when ALL of the following are met:

ALL of the following

Member age is from birth up to 3 years of agebirth up to 3 years
Member is enrolled in Mass General Brigham Health Plan, MGB ACO, or Commercial plan
Member is involved in an Early Intervention program (IFSP supports EIBI treatment)IFSP supports EIBI
Member has a diagnosis of Autism Spectrum Disorder (ASD) documented per the most recent DSM editionASD diagnosis per DSM
Diagnosis must be by qualified clinician
Diagnosis made by a physician, psychologist, or psychiatrist experienced in diagnosis of autism and documentation supports behaviors attributable to ASD
EIBI provider (Specialty Service Provider - SSP) and staff must be approved by Massachusetts Department of Public Health (MDPH) prior to billingMDPH approval required

Prior Authorization / Plan Specific Authorization

Authorization requirements vary by product:

Product-specific

MGB ACO & Commercial: For MGB ACO and Commercial plans: prior authorization to Mass General Brigham Health Plan is required for EIBI servicesPrior authorization to Mass General Brigham Health Plan
Providers must submit prior authorization requests to Mass General Brigham Health Plan
Members up to age 3 not involved in Early Intervention: For members up to age 3 who are NOT involved in Early Intervention: service is ABA-Applied Behavioral; authorization requirements: contact Optum Behavioral HealthContact Optum Behavioral Health
Age 3 and older: For members age 3 and older: service is ABA-Applied Behavioral Analysis; authorization requirements: contact Optum Behavioral Health

Place of Service and Service Limits

Coverage conditions and limits:

ALL of the following

Place of Service: Policy applies to qualifying and authorized places of service as per National POS code setQualifying/authorized POS per national code set
Services must be at qualifying/authorized POS
Service limits: MDPH EIBI (SSP) service and visit limits apply (refer to MDPH Early Intervention guidance)MDPH service and visit limits
Supervision requirement: Services must be provided by or supervised by a qualified and certified Board Certified Behavioral Analyst (BCBA) specialist as defined by MDPH

Not Reimbursed (Exclusions)

Mass General Brigham Health Plan does NOT reimburse the following:

ANY of the following

Research/Experimental: ASD research-based programs, experimental treatments, or use of tools not approved by MDPHNot approved by MDPH
Educational services such as tutoring or home schooling
Recreational services not described or included within the scope of EIBI or SSP services
Non-MDPH Providers: Visits not conducted by MDPH approved providersMDPH approval required

Billing codes, diagnosis codes, and modifiers

Modifiers required to identify provider level/serviceModifier

HO	Master's Degree Level
HN	Bachelor's Degree Level
U1	Medicaid Level of Care 1
U2	Medicaid Level of Care 2
TL	Early Intervention/Individualized Family Service Plan (IFSP)

Providers are required to bill the listed CPT/HCPCS codes effective 10/01/2022 and must bill units in 15-minute increments. When two or more specialty services are provided on the same date, providers must list each service on separate lines with the number of units for each service and include the appropriate servicing provider type modifier.

What providers must do

Prior Authorization

Prior authorization required for EIBI (MGB ACO & Commercial)

Providers must submit prior authorization requests for EIBI services to Mass General Brigham Health Plan for members in MGB ACO and Commercial plans; prior authorization is required prior to billing.

Affected products: MGB ACO and Commercial plans

Documentation Required

Diagnostic and IFSP documentation

Provider must document ASD diagnosis by a qualified clinician experienced in autism, documentation of behaviors attributable to ASD, and IFSP support for EIBI treatment.

Diagnosing clinicians must be a physician, psychologist, or psychiatrist experienced in autism
Documentation must support behaviors attributable to Autism Spectrum Disorder and show IFSP support for EIBI

Billing Rule

Billing units and line item rules

Providers must bill units in 15-minute increments and when two or more specialty services are provided on the same date, list each service on separate lines with units and the appropriate servicing provider type modifier.

Bill in 15-minute increments
When 2+ specialty services same date: separate lines with units and appropriate servicing provider type modifier.

Billing Rule

MDPH approval required to bill

All EIBI providers and staff must be approved by the Massachusetts Department of Public Health prior to billing; services not conducted by MDPH-approved providers are not reimbursed.

Services delivered by providers or staff not approved by MDPH are not reimbursed.

Billing Rule

Diagnosis code required on claim

Claims must include an appropriate primary ICD-10 diagnosis from the autism spectrum codes based on clinical determination.

F84.5
F84.8
F84.0
F84.3
F84.9
F84.2

Key definitions

Definitions

Early Intensive Behavioral Intervention (EIBI)Services for children involved in an Early Intervention program who receive an ASD diagnosis from a qualified clinician; also referenced as Early Intervention Applied Behavioral Analysis (EI-ABA)

Specialty Service Provider (SSP)Agencies that Early Intervention programs may contract with to provide EIBI services; must be approved by the Massachusetts Department of Public Health

Autism Spectrum Disorder (ASD)Developmental disorder causing social, communication, and behavioral challenges; diagnosis per DSM by a qualified clinician

Policy updates & effective dates

2022-10-01detail

October 1, 2022 code update (added/updated CPT/HCPCS coding requirements). Providers required to bill listed CPT/HCPCS codes effective 10/01/2022 and use 15-minute billing increments.

2024-01-01detailLatest

January 1, 2024 annual review with no policy change.

Policy Summary

PayerMass General Brigham Health Plan

PolicyEarly Intensive Behavioral Intervention (EIBI) Policy

Policy CodePolicy N/A

Change TypeCode update (Oct 1, 2022)Annual review (Jan 1, 2024)

Effective Date

Next Review Date

Key ActionSubmit prior authorization requests for EIBI services to Mass General Brigham Health Plan for members in MGB ACO and Commercial plans prior to billing.

SourceLink

On This Page

Contact Optum Behavioral Health

BCBA supervision required

Unassigned POS: Services reported with an 'unassigned' place of service code'Unassigned' POS code

Unauthorized Services: Unauthorized services that require authorization as defined in this policyAuthorization required

Missed Appointments: Missed appointments