Prior authorization required for levels of care and specialized services

Prior authorization is required for outpatient, IOP, PHP, inpatient levels of care and specialized services (including ABA, behavioral evaluations, TMS, and ECT) for members under 18; providers must submit requests demonstrating medical necessity per the policy's clinical criteria.

• Applies to ABA, behavioral evaluations, TMS, ECT and level-of-care authorizations
• Coverage decisions subject to member's benefit plan terms

ABA prior authorization requirement

Prior authorization is required for all ABA therapy codes listed (97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T). A 97151 behavior identification assessment by a QHP is required prior to initiating ABA and for periodic reassessments per policy.

• Submit BCBA-authored BIP/ABA Treatment Plan and required assessments with PA request
• 97151 reserved for initial and periodic comprehensive reassessments (not routine weekly adjustments)

Prior authorization required for 0362T

Prior authorization must be obtained before performing 0362T (behavior identification supporting assessment for severe destructive behavior); 0362T requires two or more trained technicians on-site and a BCBA/BCBA‑D physically present and interruptible.

• 0362T is in-person only and not billable via telehealth
• Environment must be customized for safety; prior authorization required before session

Prior authorization & preconditions for 0373T

0373T requires prior authorization and all 0362T prerequisites; 0373T must be delivered in-person with multi‑technician staffing, BCBA on-site, billing calculated as total technician time, and may not be billed concurrently with 97155 for the same session.

• Clinical necessity of multi‑technician staffing must be documented
• Billing = combined technician-hours (e.g., 3 techs x 3 hours = 9 tech-hours = 36 units)
• 0373T cannot be billed concurrently with 97155 for same session

6-month authorization and reassessment

Initial authorizations and reauthorizations for ABA are issued for 6‑month periods; providers must perform a formal BCBA reassessment and include Vineland‑3 plus at least one criterion‑referenced instrument at each 6‑month reauthorization.

• Reauthorization must include progress summary, updated BIP, Vineland‑3 and criterion‑referenced results
• Formal BCBA reassessment required at least every 6 months

Prior authorization for testing, TMS, and ECT

Prior authorization is required for psychological/neuropsychological testing, and for TMS and ECT; testing is typically limited to once per calendar year per testing type, TMS initial courses (up to 36 sessions) and ECT courses (typically 6–12 sessions) require meeting specified clinical criteria and PA.

• Testing (96130/96132 etc.) usually limited to once per calendar year per testing type
• TMS (ages ≥15) initial acute course authorized up to 36 sessions with PA
• ECT (ages ≥13) typical acute course 6–12 sessions with PA and medical/anesthesia clearance

Prior Authorization Required

Initial and continued authorizations are required for PHP and ABA services; initial PHP authorization requires meeting intensity, safety, family involvement, and appropriate scoring (CALOCUS‑CASII or ASAM), and ABA requires current ASD diagnosis and provider qualifications documented with the PA request.

• PHP requires minimum 20 hours/week of active treatment for admission
• ABA authorizations require current documented DSM‑5‑TR ASD diagnosis and BCBA-authored treatment plan

ABA prior authorization and 97151 use

Prior authorization for ABA must include an individualized BCBA‑authored Behavior Intervention Plan or ABA Treatment Plan and required assessments; 97151 is for formal initial assessment or periodic reassessment and should be submitted with PA requests when initiating or reassessing ABA.

• BCBA-authored BIP must include diagnosis, baseline data, SMART goals, intensity justification, caregiver plan, supervision structure
• 97151 results (Vineland‑3, criterion‑referenced instrument) must be included for initial or 6‑month reassessment PAs

Ohio: Prior authorization required

In Ohio, prior authorization is required for ABA and related services; services must be prescribed/ordered by specified autism‑trained clinicians as required by the Ohio statute and documented in the PA submission.

• Ohio statute requires PA and prescriber qualifications for ABA services
• Verify prescriber documentation per Ohio requirements when submitting PA

Prior authorization for ABA services

Comprehensive ABA Therapy replaces the prior ABA section and PA is required per the policy for ABA categories 1–8; providers must follow the integrated ABA criteria (assessment, supervision, caregiver participation, hour caps) when requesting authorization.

• Use CHP ABA criteria (Sections 4[Z] and 5[Z]) as supporting clinical standards for PA requests
• PA submissions must address supervision ratio, caregiver participation, required assessment tools, and requested hours vs age‑based limits

Prior authorization alignment

Prior authorization decisions must align with the member's specific benefit plan; inclusion of a procedure code in this policy does not guarantee coverage — verify plan terms and any applicable state mandate before approving services.

• Coverage is subject to the member's certificate of coverage and plan-specific limitations
• State statutes apply to fully insured plans; ASO/self-funded plans may be governed by CHP criteria instead

MHPAEA and prior authorization application

MHPAEA applies to behavioral health prior authorization and clinical criteria; CHP applies prior authorization and NQTLs comparably to analogous medical/surgical benefits and will perform parity analyses before enforcing state caps or restrictive NQTLs for MHPAEA‑covered plans.

• MHPAEA compliance prohibits applying BH limits more restrictive than comparable medical/surgical benefits
• CHP maintains NQTL comparative analyses and applies caregiver participation and progress requirements consistent with parity

Intensity determination and step-down

Treatment intensity must be individualized by the supervising BCBA based on comprehensive assessment; as goals are mastered, step‑down from comprehensive to focused intensity (and eventually discharge) is expected and should be reflected in updated treatment plans.

• BCBA documents clinical rationale for requested intensity and ties hours to evidence‑based tiers
• Step‑down planning must be included in treatment plan and considered at each reassessment

Assessment timing requirements

97151 must be billed only for formal initial behavior identification assessments and periodic reassessments (typically every 6 months); it is not appropriate to bill 97151 for routine weekly or daily treatment adjustments.

• Initial 97151 up to 8 units/day; total initial assessment typically 24–32 units; periodic reassessment typically 16–24 units
• 97151 includes face‑to‑face and non‑face‑to‑face components and must result in or update the BIP

Required prior medication trials

Initial prior medication trial requirements apply to neuromodulation: for TMS, documentation of at least one adequate antidepressant trial in the current episode is required unless contraindicated; for ECT, failure of ≥2 adequate antidepressant trials (or documented contraindication) is required for many indications.

• Document adequacy of prior antidepressant trials (dose, duration ≥4 weeks) or contraindication in PA request
• Include validated severity scales and prior treatment history with PA

Step-down Planning

Providers must plan for clinically appropriate step‑down: members should generally be stepped down to IOP or outpatient when clinically safe; continued authorizations require documented progress toward step‑down in the reauthorization materials.

• Document measurable progress and step‑down planning in reauthorization request
• Reauthorization requires Vineland‑3 and criterion‑referenced assessment every 6 months

Step-therapy limitations (MHPAEA)

Fail‑first or step‑therapy requirements that force trial of less‑intensive ABA before medically necessary comprehensive ABA are not imposed for fully insured plans subject to MHPAEA unless clinically justified; CHP evaluates parity before applying such policies.

• MHPAEA prohibits arbitrary fail‑first requirements for ABA when not comparable to medical/surgical benefits
• Clinical justification required if step‑therapy is proposed

ASO plans: Use CHP criteria

For ASO/self‑funded ERISA plans, state mandates generally do not apply; use CHP policy clinical criteria (Sections 4[Z], 5[Z]) for authorization decisions for ABA services under ASO arrangements.

• Verify plan type (ASO vs fully insured) before applying state statutory mandates
• CHP clinical criteria govern ASO plan determinations

Operational sequencing implications

Operational revisions (supervision ratios, caregiver participation thresholds, assessment tool requirements, hour caps, and telehealth rules) have been integrated and may affect authorization sequencing and required documentation; providers must address these elements in PA submissions.

• CHP requires BCBA supervision ≥10% of direct treatment hours and ≥2 face‑to‑face contacts/month
• Caregiver training plan with attendance monitoring (≥80%) and specified assessment tool use (Vineland‑3, VB‑MAPP/ABLLS‑R/AFLS, ADOS‑2/ADI‑R, FBA) must be documented

Medical necessity and prior authorization

Medical necessity determinations must be made case‑by‑case by licensed behavioral health professionals using all available clinical information; prior authorization requirements and clinical criteria govern service authorization for outpatient, IOP, PHP, inpatient, and specialized services.

• Licensed clinical reviewers apply the policy criteria in individual cases
• PA requests must include sufficient clinical documentation to support medical necessity determinations

Required documentation for authorization

Provide a current DSM‑5‑TR ASD diagnosis established by a qualified provider and a comprehensive diagnostic evaluation including at least one validated diagnostic instrument (ADOS‑2 or ADI‑R preferred), Vineland‑3 baseline, and a criterion‑referenced instrument (VB‑MAPP/ABLLS‑R/AFLS) when requesting authorization.

• If diagnostic evaluation is older than 36 months, a re‑evaluation with a validated instrument is required prior to initial authorization
• Diagnostic documentation must include instruments used, dates, and diagnosing provider credentials

Required treatment plan elements

Initial authorization requires submission of a BCBA‑authored Behavior Intervention Plan (BIP) or ABA Treatment Plan that includes: current ASD diagnosis documentation, objective baseline data (Vineland‑3), SMART goals with mastery criteria, evidence‑based strategies, treatment intensity justification tied to age‑based limits, treatment setting rationale, mandatory caregiver participation plan, supervision structure, coordination of care, and discharge criteria.

• BIP must document mastery criterion (minimum 80% accuracy across 3 consecutive sessions) and measurable baseline data for each target
• Caregiver training frequency (1–4 hrs/month) and attendance monitoring (≥80%) must be specified

Assessment documentation

97151 assessment documentation must include face‑to‑face and non‑face‑to‑face components, validated instruments (Vineland‑3 baseline and each 6‑month reassessment), and must result in or update an individualized BIP/ABA Treatment Plan.

• 97151 billed only for initial assessments and periodic reassessments (not routine treatment adjustments)
• Include Vineland‑3 and at least one criterion‑referenced instrument with the 97151 documentation

Prior authorization for Category III assessment

Prior authorization is required before conducting 0362T category‑III behavior identification supporting assessment for destructive behavior; submit PA that documents severe destructive behavior, planned functional analysis, two or more technicians, safety‑configured environment, and on‑site QHP availability.

• 0362T requires BCBA‑D or BCBA physically on‑site and immediately interruptible
• 0362T is not billable via telehealth

Required initial treatment plan elements

Initial BCBA‑authored BIP/ABA Treatment Plan must include ASD diagnosis documentation (ICD‑10 code and diagnostic details), Vineland‑3 baseline data, SMART goals with mastery criteria, evidence‑based intervention strategies, treatment intensity justification consistent with age‑based limits, treatment setting rationale, mandatory caregiver participation plan, supervision structure, coordination of care, progress measurement methodology, and discharge criteria.

• Confirm required assessments (Vineland‑3, VB‑MAPP/ABLLS‑R/AFLS, FBA if behavior reduction goals present) have been administered
• Document planned supervision ratio and formats to meet 10% monthly BCBA supervision and ≥2 face‑to‑face contacts/month

Reauthorization documentation

For each 6‑month reauthorization providers must submit a progress summary with objective data for each active goal, updated Vineland‑3 and at least one criterion‑referenced assessment, updated BIP, caregiver engagement documentation (attendance ≥80% target), coordination of care updates, and hour utilization versus authorized hours.

• Progress summary should include graphs comparing baseline to current performance for each goal
• Include caregiver competency data and documentation of accommodations if attendance <80%

Required clinical documentation

Document clinical indications, standardized instruments used, test administration time, interpretation, report, adequacy of medication trials, device clearance and supervision for TMS, consent/assent and pre‑ECT medical/anesthesia clearance, and daily active treatment documentation for inpatient authorizations.

• Testing must be billed with appropriate administration codes and limited to once/year per testing type unless justified
• TMS PA must include device FDA clearance and psychiatrist supervision documentation

Required Clinical Documentation (ASAM/ SUD / PHP)

For inpatient stays document ASAM 6‑dimension assessment (for SUD), DSM‑5‑TR diagnosis, daily active treatment, discharge planning, family/caregiver participation, and appropriate level‑placement documentation (CALOCUS‑CASII or ASAM) in the inpatient record.

• Professional services require provider credentials, clinical rationale, and session notes in the inpatient chart
• Daily active treatment must be documented to support continued inpatient authorization

Inpatient Professional Service Documentation

Professional services during an authorized inpatient psychiatric or SUD stay require documentation in the inpatient record with date, provider credentials, clinical rationale, and, for psychotherapy, session notes documenting goals, content, and modality.

• Family therapy and group therapy documentation rules apply (90846/90847, 90849/90853)
• Use appropriate inpatient professional codes with documentation of clinical appropriateness

ABA session-note and reauthorization documentation requirements

Daily session notes for every ABA session (97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T) must include date/time/duration, setting, provider name/credentials/BACB number, goals targeted (by BIP name/code), objective data collected per goal, caregiver involvement, ABC behavior incident format, and any plan modifications; six‑month reauthorization updates must include quantitative progress per goal, updated Vineland‑3 and criterion‑referenced assessment results, hour utilization vs authorized, and caregiver competency data.

• Session notes must contain ABC format for incidents and objective data for each targeted goal
• Six‑month updates must include utilization vs authorized hours and transition/discharge plan

Ohio PA and prescriber documentation

In Ohio, PA submissions must include documentation that services are prescribed/ordered by an autism‑trained psychologist, developmental pediatrician, or certified nurse specialist/NP as required by the Ohio statute; include prescriber credentials in the PA request.

• Verify Ohio prescriber/orderer qualifications when submitting PA
• Include required physician review/prescription at reauthorization when mandated

Texas ECT attestation/documentation

Texas requires additional physician attestation and compliance with state ECT consent and documentation requirements for pediatric ECT; include Texas‑specific attestation and facility/provider compliance in PA submissions when applicable.

• For Texas pediatric ECT, confirm treating facility certifications and physician attestation per Texas Health & Safety Code
• Include documented consent and assent in PA packet

Assessment and documentation requirements (summary)

Required assessment tools listed in the policy revision include Vineland‑3, VB‑MAPP/ABLLS‑R/AFLS, ADOS‑2/ADI‑R for diagnostic confirmation, and Functional Behavioral Assessment when behavior reduction goals are present; include results and dates of these instruments in PA submissions.

• Vineland‑3 required at baseline and every 6 months; ADOS‑2/ADI‑R required for diagnostic confirmation at initial authorization
• Use criterion‑referenced instrument selected (VB‑MAPP/ABLLS‑R/AFLS) to set treatment targets and measure progress

Documentation expectations

Documentation should follow the policy's ABA documentation standards and is intended for licensed clinical reviewers and AI‑assisted prior authorization systems; include state statute references and cited clinical guidance when making determinations and retain documentation supporting any accommodations offered to caregivers.

• Documentation expectations include referencing applicable state statutes and CHP guidance
• PA reviewers should consult legal/compliance for MHPAEA parity questions

Coverage depends on benefit plan

Coverage determinations depend on the member's specific benefit plan and certificate of coverage; inclusion of a service or CPT/HCPCS code in this policy does not guarantee coverage and plan terms must be verified before authorization.

• Verify member's benefit plan and certificate of coverage at time of PA/claim adjudication
• State mandates apply only to fully insured plans unless ASO plan voluntarily adopts them

Diagnostic confirmation required

Failure to provide a current DSM‑5‑TR ASD diagnosis established by a qualified provider and supported by a comprehensive diagnostic evaluation with a validated instrument (e.g., ADOS‑2/ADI‑R) may result in denial of ABA PA requests.

• If original diagnostic evaluation is older than 36 months, a re‑evaluation with a validated instrument is required prior to initial authorization
• Screening instruments alone are insufficient for diagnostic confirmation

Billing 0373T concurrency restriction

Billing 0373T concurrently with 97155 for the same session will not meet criteria and may be denied because indirect QHP services are bundled into 0373T.

• 0373T bundles indirect services; 97155 cannot be billed for same session as 0373T

Requests exceeding BCBA supervisory capacity risk flagging

Requests that would authorize hours exceeding a BCBA’s documented supervisory capacity will be flagged for clinical review and may be denied; providers must include supervision documentation showing the BCBA can meet the minimum 10% supervision ratio and ≥2 face‑to‑face contacts/month.

• Include BCBA supervision schedule and documentation to demonstrate capacity
• Requests that create a demonstrable supervisory deficit do not meet criteria

Caregiver participation and reauthorization risk

If caregiver participation falls below the ≥80% attendance threshold, providers must document barriers and accommodations offered before any reduction in authorization; continued failure after documented accommodations may lead to reduction or non‑authorization of the caregiver training component but not automatic termination of the entire ABA program.

• Document accommodations attempted (schedule flexibility, telehealth for caregiver training, interpreters) before reducing caregiver training authorization
• Caregiver participation shortfall alone is not grounds for terminating all ABA services

Duplicate psychiatric diagnostic evaluation billing

Billing both 90791 and 90792 by the same provider on the same date of service is prohibited and may be denied; submit the appropriate single evaluation code per the service performed.

• 90791 (no medical services) and 90792 (with medical services) cannot be billed by same provider on same date

ABA Diagnostic Basis Required

ABA services will be denied if billed for members without a current, documented DSM‑5‑TR ASD diagnosis established through a comprehensive evaluation with validated instruments; ABA billed under non‑ASD diagnoses does not meet criteria.

• Ensure ASD diagnosis codes (F84.0, F84.5, F84.8, F84.9) and supporting evaluation are included with PA
• Rett syndrome (F84.2) and childhood disintegrative disorder (F84.3) are not qualifying under this policy

Service-Type Exclusions

Services that are custodial, educational services the school district must provide under IDEA/IEP, non‑evidence‑based interventions (e.g., Floortime/DIR alone, chelation), and other listed exclusions will be denied as not meeting medical necessity.

• ABA during school hours duplicative of IEP services is excluded
• Non‑evidence‑based standalone interventions listed in policy are not covered under ABA codes

Provider Qualification/Billing Errors

Incorrect provider billing will result in denial: examples include 97151 billed by an RBT/BCaBA acting independently, 97155 billed without face‑to‑face patient presence, and Category III codes billed without required on‑site QHP or two technicians.

• 97151 must be billed by BCBA‑D, BCBA, or credentialed QHP only
• 0362T/0373T require QHP physically on‑site and ≥2 technicians; missing these elements risks denial

Documentation gaps risking denial

Missing a BCBA‑authored individualized BIP/ABA Treatment Plan, missing objective baseline data (Vineland‑3), missing required assessments, missing caregiver participation documentation when training included, or lapsed authorization without timely reauthorization submission will risk denial of the PA.

• Ensure BIP includes baseline data, SMART goals, mastery criteria, supervision structure, and required assessment confirmations
• Timely reauthorization submission required; services without current PA are not eligible for retroactive authorization except by exception

Clinical justification and progress risks

Requests exceeding age‑based weekly hour caps without extraordinary clinical justification will be subject to heightened review and may be denied; lack of measurable progress over 6 months after appropriate plan revision may lead to reduction or non‑authorization of continued ABA at the same intensity.

• Age‑based caps (policy summary): up to 40/30/25/20 hrs/week by age group; Ohio statutory cap 20 hrs/week for children <14
• Provide exceptional clinical justification and documentation when requesting hours above policy maxima

Parity-triggered denial risk

Applying state‑mandated dollar caps, visit limits, or age restrictions may trigger an MHPAEA parity review; CHP will evaluate MHPAEA compliance before enforcing state caps on fully insured plans, and such caps could be deemed unenforceable if more restrictive than comparable medical/surgical benefits.

• MHPAEA comparison required before applying state dollar caps or age limits to fully insured plans
• ASO/self‑funded plans are generally exempt from state mandates

State cap/age-limit denial risk

Statutory annual dollar caps and age or weekly hour limits identified in state mandates (e.g., FL $36,000/yr; GA $35,000/yr; OH 20 hrs/week for children under 14) may be treated as QTLs and require parity analysis prior to enforcement for MHPAEA‑covered fully insured plans.

• Curative will perform MHPAEA parity analysis before applying state caps to fully insured plans
• ASO/self‑funded ERISA plans generally follow CHP clinical criteria, not state mandates

State mandate vs federal parity / ASO exception

State mandates that are more restrictive than comparable medical/surgical benefit limits may be superseded by federal MHPAEA requirements; for ASO/self‑funded ERISA plans, state mandates generally do not apply and CHP policy criteria govern.

• Verify plan type and applicable law before applying state mandate restrictions
• Consult legal/compliance for final determinations on parity and enforceability

Verification and benefit limitations

Before finalizing authorizations, verify the member's benefit plan terms, state statute applicability, and any plan‑specific limitations; failure to verify plan and statute applicability at claim adjudication may lead to denial.

• Confirm whether the plan is fully insured or ASO/self‑funded to determine applicability of state mandates
• Document verification steps in the authorization record