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    v1.0.30
    OpenPayerPolicy UpdatesMississippi Insurance DepartmentMississippi Autism Coverage Prior Auth | OpenPayer
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    CurrentMississippi Insurance DepartmentPolicy N/A

    Autism Spectrum Disorder Benefits and Applied Behavior Analysis

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    This document describes Ambetter of Magnolia coverage for screening, diagnosis, and medically necessary treatment of autism spectrum disorder under Mississippi law. It identifies covered autism treatment categories, ABA billing codes, prior authorization requirements, claim coding instructions, and provider contacts.

    Policy Summary
    PayerMississippi Insurance Department
    PolicyAutism Spectrum Disorder Benefits and Applied Behavior Analysis
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionCall 1-877-687-1187 for prior authorization requests, or submit the outpatient treatment request form by fax to 1-855-283-9097.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    4Autism treatment categories
    16ABA billing code entries
    1-877-687-1187Provider authorization number
    FirstClaim diagnosis position
    7
    Policy Summary
    PayerMississippi Insurance Department
    PolicyAutism Spectrum Disorder Benefits and Applied Behavior Analysis
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionCall 1-877-687-1187 for prior authorization requests, or submit the outpatient treatment request form by fax to 1-855-283-9097.
    SourceLink
    On This Page
    Policy ScopeAutism Spectrum Disorder CoverageApplied Behavior Analysis CoverageBehavioral Health Treatment ModalitiesABA Billing and CodingAuthorization and Claims Requirements

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    Mississippi ABA providers listed

    Policy Scope

    This policy addresses screening, diagnosis, and treatment of autism spectrum disorder under Mississippi law. Covered treatment includes medically necessary habilitative or rehabilitative services, including applied behavior analysis and other professional or counseling services intended to develop, maintain, or restore functioning to the extent possible. It also includes counseling and therapy provided by appropriately licensed or certified professionals, as well as assessments, evaluations, and diagnostic tests when medically necessary.

    Autism Spectrum Disorder Coverage

    Autism Spectrum Disorder Diagnosis and Treatment

    Coverage is provided for screening, diagnosis, and treatment of autism spectrum disorder when medically necessary.

    ALL of the following

    • Screening for autism spectrum disorder is covered.
    • Assessments, evaluations, or tests to diagnose an individual with autism spectrum disorder are covered.
    • Treatment of autism spectrum disorder is covered when medically necessary.

      Coverage applies to an individual diagnosed with autism spectrum disorder.

    Covered Autism Treatment Services

    For an individual diagnosed with autism spectrum disorder, covered treatment includes the following types of care when prescribed, provided, or ordered for the individual.

    Covered services

    • Habilitative or rehabilitative services, including applied behavior analysis, or other professional or counseling services necessary to develop, maintain, and restore the individual's functioning to the extent possible.

      Ambetter of Magnolia identifies ABA billing codes 0359T, 0360T, 0361T, 0362T, 0363T, 0364T, 0365T, 0366T/0367T, 0368T, 0369T, 0370T, 0371T, 0372T, 0373T, and 0374T. Codes may be specific to the first 30 minutes and/or combinable as clinically appropriate.

    • Counseling services provided by a licensed psychiatrist, licensed psychologist, professional counselor, or clinical social worker.
    • Therapy services provided by a licensed or certified speech therapist, speech-language pathologist, occupational therapist, physical therapist, or marriage and family therapist.
    • Services must be prescribed, provided, or ordered for an individual diagnosed with autism spectrum disorder.

    Applied Behavior Analysis Coverage

    Applied Behavior Analysis

    Covered when medically necessary for autism spectrum disorder.

    ABA coverage: The individual is diagnosed with autism spectrum disorder and applied behavior analysis is prescribed, provided, or ordered as habilitative or rehabilitative care necessary to develop, maintain, or restore functioning to the extent possible.

    Behavioral Health Treatment Modalities

    Electroconvulsive Therapy

    Prior authorization is required for this treatment modality.

    Electroconvulsive therapy authorization: Electroconvulsive therapy is a psychiatric treatment service subject to prior authorization.

    Applied Behavior Analysis

    Covered when medically necessary for autism spectrum disorder; the document lists specific covered ABA billing codes.

    ABA treatment: Applied behavior analysis is covered as medically necessary habilitative or rehabilitative treatment for an individual with autism spectrum disorder.

    Covered ABA billing codes are 0359T, 0360T, 0361T, 0362T, 0363T, 0364T, 0365T, 0366T/0367T, 0368T, 0369T, 0370T, 0371T, 0372T, 0373T, and 0374T.

    ABA Billing and Coding

    Covered ABA CodesCPTCovered
    0359TABA code covered by Ambetter
    0360TABA code covered by Ambetter
    0361TABA code covered by Ambetter
    0362TABA code covered by Ambetter
    0363TABA code covered by Ambetter
    0364TABA code covered by Ambetter
    0365TABA code covered by Ambetter
    0366T/0367TABA codes covered by Ambetter; codes are either specific to the first 30 minutes and/or combinable as clinically appropriate
    0368TABA code covered by Ambetter
    0369TABA code covered by Ambetter
    1–10 of 15
    1/2
    ABA Time and Code Combination
    First 30 minutesABA codes may be specific to the first 30 minutes.
    Code combinationsABA codes may be combined as clinically appropriate.
    Combined entryThe 0366T/0367T entry is listed as a combined ABA code entry.

    Authorization and Claims Requirements

    Prior Authorization

    Obtain prior authorization for designated services

    Prior authorization is required for designated psychiatric, substance use disorder, rehabilitation, crisis stabilization, residential, outpatient, testing, assessment, and treatment-plan services.

    • Inpatient psychiatric care, inpatient SUD care, inpatient rehabilitation, and crisis stabilization
    • Behavioral health and SUD residential treatment, electroconvulsive therapy, intensive outpatient programs, and detoxification
    • Psychiatric neurological testing, mental health assessment, day treatment, partial hospitalization, applied behavior analysis, and mental health service plans
    Note

    Use the required authorization route

    Providers should call 1-877-687-1187 for authorization requests. For outpatient services, providers may submit the Outpatient Treatment Request form from the Ambetter Magnolia Health website by fax to 1-855-283-9097.

    • Authorization telephone number: 1-877-687-1187
  1. Outpatient submission: Outpatient Treatment Request form
  2. Fax: 1-855-283-9097
    3. Note

    Note the 2017 ABA authorization exception

    The document states that ABA did not require prior authorization for 2017. This is a historical exception stated specifically for 2017.

    • Service: applied behavior analysis (ABA)
    • Exception period stated in the document: 2017
    Documentation Required

    Submit the authorization request

    For services requiring prior authorization, call 1-877-687-1187. For outpatient services, submit the Outpatient Treatment Request form available on the Ambetter Magnolia Health website by fax to 1-855-283-9097.

    • Call for authorization: 1-877-687-1187
    • Outpatient form: Outpatient Treatment Request form
    • Fax submission: 1-855-283-9097
    Documentation Required

    Document medical necessity

    Autism spectrum disorder assessments, evaluations, tests, and treatment must be medically necessary for coverage.

    • Document the autism spectrum disorder diagnosis.
    • Support the medical necessity of the assessment, evaluation, test, or treatment.
    Denial Risk

    Place the primary diagnosis first

    For claims containing multiple diagnoses, Ambetter considers only the first diagnosis on the claim, regardless of the number of services. Placing the primary diagnosis in a later position may jeopardize proper payment.

    • Place the primary diagnosis in the first position.
    • Ambetter looks only at the first diagnosis on the claim.
    Prior Authorization

    Authorize designated behavioral health services

    Obtain prior authorization for designated behavioral health services, including inpatient psychiatric care, inpatient substance use disorder services, inpatient rehabilitation, crisis stabilization, residential treatment, ECT, IOP, detoxification, testing, assessment, day treatment, PHP, ABA, and mental health service plans.

    • Psychiatric and substance use disorder services: inpatient care, inpatient rehabilitation, crisis stabilization, residential treatment, ECT, IOP, and detoxification
    • Behavioral health services: psychiatric neurological testing, mental health assessment, day treatment, PHP, ABA, and mental health service plans