Prior authorization governs PA & medical necessity for BH/SUD services

This policy governs prior authorization requirements and medical necessity criteria for outpatient, intensive outpatient (IOP), partial hospitalization (PHP), inpatient care, and specialized services including ABA, TMS, and ECT for members aged 18 and over; submit PA requests with required documentation for the applicable level of care and codes listed in Section 4 and Section 3A. Authorization decisions are subject to the member's benefit plan terms.

PA required for adult ABA codes; 97151 required for initial assessment

Prior authorization is required for ABA therapy codes for members 18 and over and is governed by the adult-specific ABA section (Section 4Z); an initial behavior identification assessment (CPT 97151) is required prior to initiating treatment as specified.

97156 requires BIP training goals with measurable caregiver competency targets

CPT 97156 meets coverage criteria only when training goals are documented in the member's Behavior Intervention Plan (BIP) with measurable caregiver competency targets and are tied to the adult member's ABA program in natural environments.

97156 must support ABA implementation in natural settings and be BIP‑linked

CPT 97156 meets criteria when the caregiver/support-person training is designed to support implementation of the adult member's ABA program in natural settings (home, community, workplace) and training goals are documented in the BIP with measurable caregiver competency targets.

Coverage: 97156 covered when caregiver training criteria & consent documented

CPT 97156 is covered when all caregiver training criteria are met, including documentation of training goals in the BIP, design to support implementation of the adult's ABA program in natural settings, and consent/documentation requirements when the adult has decision‑making capacity.

Document adult consent to involve support persons for 97156 when applicable

Coverage criteria for CPT 97156 require that the training supports the adult's ABA program in natural settings and that, for adults with decision‑making capacity, the member's agreement to involve specific support persons in treatment is documented when applicable.

Authorizations and reauthorization intervals: 6 months with BCBA reassessment

Initial authorizations and reauthorizations for ABA are issued in 6‑month periods; formal BCBA reassessment is required at least every 6 months and must include Vineland‑3 and at least one criterion‑referenced instrument for reauthorization.

TMS PA and code-specific billing rules (90867/90868/90869)

TMS requires meeting specified clinical criteria and is billed per code: 90867 for the initial session (billed once per course), 90868 for subsequent delivery sessions (with a typical acute-course maximum of 36 sessions), and 90869 for motor‑threshold re‑determination with documented justification.

PA required for TMS/ECT and inpatient admissions; 90867 billed once per course

Authorization is required for TMS, ECT, and inpatient psychiatric admissions and must document that the service‑specific clinical criteria are met; initial TMS (90867) is billed once per course as the setup/mapping session.

PA required for IOP, PHP, outpatient BH/SUD services and required documentation

Prior authorization is required for specified services including IOP (H0015, S9480), PHP (S0201), outpatient behavioral health (H0004/H0005), and outpatient SUD services (H0012, H0013, H0014, H0016); PA requests must demonstrate medical necessity and include required documentation.

Adult ABA PA requires individualized review, session‑level documentation, 6‑month reauth

Prior authorization for adult ABA requires individualized medical‑necessity review with session‑level documentation (daily session notes, BIP, outcome measures) and 6‑month reauthorization evidence; PA requirements for ABA must be comparable to analogous medical/surgical PA criteria under MHPAEA.

Coverage is plan‑specific; code listing does not guarantee coverage

Coverage is determined by the member's specific benefit plan and certificate of coverage; the presence of CPT/HCPCS codes in this policy does not guarantee coverage and all services remain subject to plan terms.

PA decision timelines: standard 15 days, urgent 72 hours

Standard prior authorization decisions must be completed within 15 calendar days of receipt of all necessary clinical information; urgent PA decisions must be completed within 72 hours.

PA review must be performed by licensed clinical reviewers (policy use guidance)

This policy is intended for use by licensed clinical reviewers and AI‑assisted prior authorization systems; authorization determinations must be made by qualified clinicians using the clinical criteria in this policy.

ABA treatment intensity must be individualized; Focused = 10–25 hrs/week typical

Treatment intensity for ABA must be individualized by BCBA assessment; Focused ABA (10–25 hrs/week) is the standard upper limit for most adults while comprehensive intensity (up to 30 hrs/week for ages 18–21) requires documented extraordinary clinical justification.

Document adult member's consent/wishes regarding caregiver training participation

Document the adult member's participation or non‑participation in caregiver training consistent with their consent and wishes; when the adult has decision‑making capacity, record whether they agreed to involve specific support persons in treatment.

TMS requires documentation of prior antidepressant trial/failure or intolerance

For TMS in MDD, include documentation of prior antidepressant treatment failure or intolerance (at least one adequate trial in the current episode) unless a contraindication or documented patient preference applies.

ECT requires prior adequate medication trials for TRD definitions (≥2 trials)

ECT authorization for TRD requires documentation of prior adequate medication trials consistent with the TRD definition (failure of ≥2 adequate medication trials) or other listed indications per the ECT criteria.

Do not apply categorical step‑therapy/ fail‑first to adult ABA without clinical basis

Fail‑first or step‑therapy requirements are not applied categorically to adult ABA without clinical justification; CHP will not require trials of less‑intensive ABA as a universal prerequisite absent an individualized clinical basis in accordance with MHPAEA.

Prohibited: mandatory less‑intensive ABA trials for adults without clinical justification

Fail‑first or step‑therapy mandates that force trials of less‑intensive ABA for adults without individualized clinical justification are prohibited for fully insured plans subject to MHPAEA; clinical overrides must be permitted when justified.

Denial risk if BIP lacks documented training goals with measurable caregiver targets

Authorization or claims may be denied if training goals are not documented in the member's BIP with measurable caregiver competency targets; ensure the BIP includes measurable competency targets linked to 97156 requests.

Medical necessity determinations must be individualized and clinician‑led

Medical necessity determinations must be individualized and made by licensed behavioral health clinicians using all available clinical information; PA reviewers must apply the policy criteria on a case‑by‑case basis.

Required submissions: DSM‑5‑TR evaluation, Vineland‑3 baseline and 6‑month results, criterion‑referenced test

Submit a current DSM‑5‑TR diagnostic evaluation (ADOS‑2/ADI‑R preferred where applicable), baseline Vineland‑3 and Vineland‑3 at each 6‑month reauthorization, and at least one criterion‑referenced assessment (AFLS preferred for adults) to support authorization.

BIP must document training goals and measurable caregiver competency targets for 97156

Training goals for caregiver/support‑person sessions must be documented in the member's BCBA‑authored Behavior Intervention Plan (BIP) and include measurable caregiver competency targets; training must be designed to support implementation of the member's ABA program in natural settings.

Document adult agreement to involve specific support persons when member has capacity

When the adult member has decision‑making capacity, document the member's agreement (or documented non‑participation consistent with their wishes) to involve specific support persons in treatment; absence of such documentation may affect authorization for caregiver training codes.

Reauthorization requires Progress Summary Report, Vineland‑3, and criterion‑referenced results

At reauthorization, submit a Progress Summary Report with objective behavioral data for each active goal, updated Vineland‑3 and at least one criterion‑referenced assessment (AFLS preferred), updated BIP, support person engagement documentation, and treatment intensity justification.

When ABA co‑occurs with SLP/OT/PT: document distinct goals, quarterly coordination, avoid overlapping billing

When ABA co‑occurs with SLP/OT/PT, providers must document distinct non‑overlapping discipline‑specific goals, provide quarterly coordination communication, and not bill overlapping time blocks for simultaneous services.

Document clinical & administrative requirements for ECT/inpatient requests (medical clearance, consent, supervision)

Maintain diagnostic confirmation, medical clearance/anesthesia assessment (for ECT), informed consent, psychiatrist supervision documentation, and relevant prior acute response or treatment history when requesting ECT or inpatient services.

Maintain individualized treatment plan updates (≥90 days) and detailed daily session notes

Providers must keep individualized treatment plans with measurable goals updated at least every 90 days and maintain daily session notes documenting date/time/duration, setting, provider identity and BACB number, goals targeted, objective data, support person involvement, ABC incident format when applicable, and billing code/unit details.

Reauth submission must include Vineland‑3, criterion‑referenced results, and objective behavioral data

Reauthorization requests must include Vineland‑3 and criterion‑referenced assessment results (AFLS, VB‑MAPP, or ABLLS‑R) plus objective behavioral data demonstrating response during the prior authorization period.

Required ABA session documentation: date/time, setting, provider/BACB number, goals, objective data, support person involvement

Daily ABA session notes must include date/time/duration, setting, provider name and BACB number, targeted goals (by name or code), objective goal‑specific data, support person involvement, ABC‑formatted incident documentation, and any plan modifications; ensure billing codes and unit details are recorded.

Diagnostic currency: DSM‑5‑TR ASD evaluation required within 36 months for ABA authorization

Authorization requires a current DSM‑5‑TR ASD diagnosis within 36 months of treatment initiation; an older diagnostic evaluation (>36 months) necessitates a re‑evaluation with a validated instrument before authorizing ABA.

TMS session limit risk: >36 acute sessions without justification may be non‑covered

Exceeding 36 sessions for a standard acute TMS course without documented clinical justification may result in non‑coverage or require additional review and justification.

Denial risk: ABA billed without current comprehensive DSM‑5‑TR ASD diagnosis

Claims for ABA will be denied if billed for an adult without a current, documented DSM‑5‑TR ASD diagnosis established through a comprehensive evaluation (ICD‑10: F84.0, F84.5, F84.8, or F84.9); screening instruments alone are insufficient.

Denial risk: provider credentialing or supervision failures (BCBA ratios, improper billers)

Billing 97151, 97155, or technician codes by improperly credentialed or unsupervised staff, or failing to meet BCBA supervision ratio (≥10% of technician monthly direct hours and ≥2 face‑to‑face contacts/month) may trigger denial.

Do not bill custodial, non‑evidence‑based, or non‑billable time as ABA — risk of denial

Services that are custodial, non‑evidence‑based ABA derivatives, or non‑billable time (travel, administrative time, no‑shows) billed as ABA are excluded and will be denied.

Ohio adult applicability: ORC § 3923.84 generally does not apply to adults 21+

For fully insured Ohio plans, services for members age 21 and over may not be covered under the Ohio mandate (ORC § 3923.84); verify applicability and perform MHPAEA parity analysis when adjudicating adult Ohio claims.

Verify benefit plan terms & current state statutes for authorization decisions

All authorization decisions are subject to the member's specific benefit plan terms and state statute provisions should be verified against current law at time of claim adjudication.