CurrentNew Mexico Health Care AuthorityPolicy N/A

Autism Intervention (AI) Services — Coverage Criteria (State Plan Attachment 3.1A)

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Defines coverage, practitioner requirements, evaluation and treatment stages (Stage 1–3) for Autism Intervention services for individuals diagnosed with or at risk for Autism Spectrum Disorder under New Mexico's Medicaid State Plan.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyAutism Intervention (AI) Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2022

Next Review DateN/A

Key ActionDocument a Comprehensive Diagnostic Evaluation (CDE) and an individualized Integrated Service Plan (ISP) before initiating Stage 2 or Stage 3 AI services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Program stages

Multi-informantCDE expectations

BCBA/BCBA-DStage 2 primary creds

Measurable improvementISP requirement

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CurrentNew Mexico Health Care AuthorityPolicy N/A

Autism Intervention (AI) Services — Coverage Criteria (State Plan Attachment 3.1A)

Customize your policy alerts

Sign up for all New Mexico Health Care Authority policy alerts

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Policy Summary

PayerNew Mexico Health Care Authority

PolicyAutism Intervention (AI) Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2022

Next Review DateN/A

Key ActionDocument a Comprehensive Diagnostic Evaluation (CDE) and an individualized Integrated Service Plan (ISP) before initiating Stage 2 or Stage 3 AI services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Program stages

Multi-informantCDE expectations

BCBA/BCBA-DStage 2 primary creds

Measurable improvementISP requirement

1:10BA supervision ratio

40hAI training (non-RBT BTs)

Coverage Criteria for Autism Intervention (AI) Services

General coverage criteria for AI services

Covered when ALL of the following are met

Eligibility and Staging: 1) Individual has a diagnosis of Autism Spectrum Disorder (ASD) or is at risk for ASD per DSM/ICD; 2) Stage 1: referral to an Autism Evaluation Practitioner (AEP) and completion of a Comprehensive Diagnostic Evaluation (CDE) or Targeted Evaluation when a full CDE is not medically warranted; 3) An Integrated Service Plan (ISP) is developed by the AEP that recommends Stage 2 services when indicated; 4) Stage 2: Behavior Analytic Assessment (conducted by a qualified Behavior Analyst/BCBA or qualified psychologist) and development of an Autism Intervention Treatment Plan (AITP); 5) Stage 3: delivery of Stage 3 interventions by a Behavior Analyst (BA) and a Behavioral Technician (BT) as specified in the AITP.

Stages are sequential and linked (Stage 1 → Stage 2 → Stage 3).

Documentation content criteria

CDE and ISP content requirements

CDE content: Comprehensive Diagnostic Evaluation (CDE) must be multi-informant, multi-source and multi-modal (including direct observation/interaction, interviews, and review of medical/educational records), include assessment of developmental/intellectual, adaptive, social, speech/language, and medical/neurological functioning, and be ASD-specific to support differential diagnosis and identify co-morbid conditions. For EPSDT-aged recipients, include review of educational or early intervention records.

If a full CDE is not medically warranted, a Targeted Evaluation or Targeted Risk Evaluation may be performed.

ISP content: If AI services are indicated, the ISP must state the AEP expects measurable improvement in ASD-related symptoms, list all services and providers (regardless of payor), align recommended services with AI interventions, document individual characteristics affecting intervention, set treatment priorities, and include a plan for ongoing monitoring linked to CDE findings.

ISP may be issued separately from the CDE report but must be individualized and linked to CDE findings.

Provider credentialing and supervision requirements

Practitioner qualification criteria (select the applicable practitioner role)

Autism Evaluation Practitioner (AEP) - Stage 1: Licensed doctoral-level clinical psychologist or a physician board-certified or board-eligible in developmental behavioral pediatrics, pediatric neurology, child psychiatry, or adolescent/adult psychiatry; must have experience/knowledge of AI services, be qualified to conduct and document a CDE or Targeted Evaluation, have advanced training/experience in ASD diagnosis and differential diagnosis, and sign attestation/documentation when requested.

Required to have an approved Provider Participation Agreement (PPA) to be reimbursed.

Behavior Analyst (BA) / BCBA or BCBA-D - Stage 2/3: BCBA® or BCBA-D® certified by the BACB® or a licensed psychologist with documented education and experience in behavior analysis meeting education, supervised experience, and continuing education requirements (including specified classroom hours, supervised field work/practicum thresholds, and continuing education). Such practitioners are eligible to supervise BAs and BTs.

Must meet MAD PPA requirements for reimbursement when applicable.

AI Practitioner/Supervisor (non-BCBA) for Stage 2 & 3: A practitioner with a master's degree recognized by BACB® (that would lead to BCBA eligibility), appropriate New Mexico licensure, clinical experience and supervised training in evidence-based ASD treatment, and documented ability to supervise direct support personnel; must provide documentation of qualifications.

Covered Stage 3 AI service list

Covered Stage 3 AI services include the following treatment/intervention categories and specified techniques:

Stage 3 service categories: Services include: (a) increasing appropriate behavior via reinforcement (positive and negative reinforcement); (b) promoting stimulus control via differential reinforcement and matching-to-sample; (c) promoting appropriate behavior via stimulus change (goal setting; modeling/imitation training; instruction/rules; prompting and prompt fading; prompting to transfer; expanding stimulus control); (d) procedures for maintaining behavior (schedules of reinforcement); (e) teaching new behaviors (shaping; chaining; task analysis; discrete trial teaching; verbal behavior - echoic, mand, tact, intraverbal; listener training); (f) preventing/reducing maladaptive behavior (antecedent methods, procedural packages, redirecting, activity schedules, behavioral momentum, providing choice, reducing response effort, non-contingent reinforcement, modeling, social stories, social skills training); (g) consequential methods for reducing maladaptive behavior (various differential reinforcement procedures, response cost, time out, overcorrection, punishment, stimulus equivalence, matching law strategies, errorless learning); (h) extinction procedures; and (i) behavior-change systems (self-management, token systems, precision teaching, incidental teaching, functional communication training, natural environment teaching, augmentative communication, PECS, Lovaas model and others).

Techniques enumerated in the policy are included within the Stage 3 benefit and are delivered by BA and BT in home, clinic, and community settings.

Practitioner qualifications and supervision

Provider qualifications required to render Stage 3 AI services:

BT qualification pathways: A Behavioral Technician (BT) must be either: (1) a Registered Behavioral Technician (RBT®) credentialed by the BACB®, OR (2) have documented training in behavior analysis without RBT credentials and meet these requirements: be >= 18 years of age; possess a minimum of a high school diploma or equivalent; complete at least 4 hours of ASD-specific training (prevalence, etiology, core symptoms, characteristics, learning differences); and complete at least 40 hours of AI training toward RBT credentialing by the BACB®.

Behavior Analysts (BAs) must provide at least 1 hour of case supervision for every 10 hours of BT intervention per individual.

The policy indicates that a Comprehensive Diagnostic Evaluation (CDE) is the expected diagnostic pathway and must be conducted per current professional practice guidelines. However, when a full CDE is not medically warranted, the policy explicitly allows for a Targeted Evaluation or a Targeted Risk Evaluation as an alternative. Documentation and content expectations for the CDE (multi-informant, multi-source, ASD-specific) support use of the CDE when clinically indicated, while the Targeted Evaluation options are acceptable when the CDE is not indicated.

In the provided source chunks there are no explicit exclusions listed for Stage 3 AI services. The Stage 3 description states that Behavior Analysts (BA) and Behavioral Technicians (BT) deliver interventions in home, clinic, and community settings, but does not specify any service- or diagnosis-based exclusions within these excerpts.

These chunks do not enumerate specific conditions or scenarios that are labeled not medically necessary. Instead, the text describes diagnostic pathways and notes that when a full CDE is not medically warranted, clinicians may perform a Targeted Evaluation or Targeted Risk Evaluation, indicating alternatives rather than listing 'not medically necessary' denials.

Within the Stage 3 service description provided, there are no explicit "not medically necessary" conditions

Provider Responsibilities, Participation, and Billing Notes

Prior Authorization
Hold approved PPA / MAD PPA and meet credentialing & attestation
Providers must hold an approved Provider Participation Agreement (PPA) or MAD PPA and meet the stated credentialing and attestation requirements to be eligible for reimbursement for Stage 1 (AEP) and Stage 2 (BA/BCBA or qualified psychologist) services.
AEPs must be licensed doctoral-level psychologists or board-certified/eligible physicians and must sign an attestation and provide documentation when requested.
BAs (BCBA/BCBA‑D) or qualified psychologists must meet MAD PPA requirements to be reimbursed.

Billing Rule
Meet practitioner qualifications; no specific billing codes listed
Providers rendering Stage 2 or Stage 3 services must meet the practitioner qualification and supervision requirements described in the policy; no separate procedural codes or prior authorization rules are specified in these sections.

Level-of-Care and Setting Criteria for Stage 3 Services

Outpatient / community-based behavioral intervention (Stage 3)

Admission to Stage 3 treatment: An AITP developed after a Behavior Analytic Assessment (Stage 2) and an ISP recommending Stage 2 services; BA and BT deliver Stage 3 services in home, clinic, or community settings.

Stage 1 and 2 must precede Stage 3.

Behavior Analytic Assessment and AITP Requirements (Stage 2)

Stage 2 assessment requirements

Behavior analytic assessment and AITP criteria

Assessment methods: Behavior Analytic Assessment must use multiple methods and informants, include direct observation, measurement and recording of behavior to identify pre-treatment levels and guide goal selection, identify strengths and weaknesses across domains, and involve the individual, legal guardians/caregivers and other professionals when selecting treatment goals and evaluating progress. The assessment informs the AITP which lists all target behaviors for BA/BT intervention.

Assessment data serve as the primary basis for evaluating response and adapting treatment.

Permitted Treatment Modalities and Techniques (Stage 3)

Applied Behavior Analysis (ABA)-style interventions

Behavior analytic interventions: Interventions include increasing appropriate behavior via reinforcement, differential reinforcement, matching-to-sample, modeling/imitation training, instruction/rules, prompting and fading, stimulus transfer, and schedules of reinforcement as part of ABA-style interventions delivered in Stage 3.

These modalities are delivered by BAs and BTs and are grounded in the AITP and ISP.

Behavior modification and skill-teaching techniques

Modalities enumerated: Modalities include reinforcement (positive/negative), differential reinforcement, matching to sample, goal setting, modeling, prompting/fading, shaping, chaining, task analysis, discrete trial teaching, verbal behavior training (echoic, mand, tact, intraverbal, listener training), antecedent methods, behavioral momentum, token systems, PECS, augmentative communication, functional communication training, natural environment teaching, precision teaching, incidental teaching, Lovaas model and other listed techniques.

Full enumerated list of behavior modification and skill-teaching techniques is specified in the policy.

Supervision and Visit Frequency Limits

BA supervision of BT

BA supervision ratioBA must provide at least 1 hour of case supervision for every 10 hours of intervention the BT renders per individual.

Supervision scopeSupervision is case-level and measured per individual (hours of BT intervention per individual determine BA supervision hours).

Noncompliance riskFailure to provide required BA supervision may risk noncompliance with practitioner requirements and affect coverage eligibility.

Definitions and Program Terms

Integrated Service Plan (ISP)

DefinitionAn individualized plan developed by an Autism Evaluation Practitioner (AEP) after diagnosis that documents recommended AI services, expected measurable improvement, all services/providers involved, treatment priorities, and monitoring plans tied to the CDE.

TimingISP is developed following diagnosis by the AEP (Stage 1) and must include recommendations for Stage 2 services when indicated.

Content requirementsISP must state expected measurable improvement, list all services (regardless of payor), identify providers and individual characteristics affecting intervention, set treatment priorities, and include ongoing monitoring plans linked to CDE findings.

Behavior Analytic Assessment / AITP

PurposeStage 2 Behavior Analytic Assessment is conducted by a Behavior Analyst to determine need for skill acquisition and behavior reduction and to inform individualized goals and interventions.

Background on Autism Intervention (AI) Program

Background: Autism Intervention (AI) services are organized as a structured, sequential three-stage program. Stage 1 is a diagnostic pathway led by an Autism Evaluation Practitioner (AEP) that typically requires a Comprehensive Diagnostic Evaluation (CDE) that is multi-informant, multi-source, and ASD-specific, with allowance for a Targeted Evaluation if a full CDE is not medically warranted. Stage 2 consists of a Behavior Analytic Assessment and development of an Autism Intervention Treatment Plan (AITP) by qualified Behavior Analysts. Stage 3 comprises delivery of behavior-analytic treatments and behavior modification services by Behavior Analysts and Behavioral Technicians in home, clinic, and community-based settings.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyAutism Intervention (AI) Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2022

Next Review DateN/A

Key ActionDocument a Comprehensive Diagnostic Evaluation (CDE) and an individualized Integrated Service Plan (ISP) before initiating Stage 2 or Stage 3 AI services.

SourceLink

On This Page

May deliver or supervise Stage 2 and Stage 3 services if minimum qualifications are documented.

Eligibility for reimbursement depends on meeting the practitioner qualifications and supervision criteria (e.g., BCBA/BCBA‑D, qualified psychologist, documented BT pathways).

Step Therapy
Follow required staged progression (Stage 1 → Stage 2 → Stage 3)
Services are delivered sequentially: Stage 1 diagnostic evaluation and ISP must occur before Stage 2 Behavior Analytic Assessment and AITP, which must precede Stage 3 treatment delivery.
Stage 1: Referral to an AEP, diagnosis, and development of an ISP.
Stage 2: Behavior Analytic Assessment and AITP follow an ISP recommendation.
Stage 3: BA and BT deliver interventions after AITP is developed.

Step Therapy
No step therapy requirements specified
No step therapy (fail‑first) requirements are specified in the policy sections for Stage 3 services.

Documentation Required
Document CDE (or Targeted Evaluation) and issue ISP tied to CDE findings
Document either a Comprehensive Diagnostic Evaluation (CDE) or a Targeted Evaluation/Targeted Risk Evaluation meeting CDE requirements, and issue a separate individualized Integrated Service Plan (ISP) linked to CDE findings when developing AI services.
CDE must be multi‑informant, multi‑modal, and ASD‑specific (include interviews, direct observation, multiple domains such as developmental, adaptive, social, speech/language, medical/neurological).
If an ISP is not part of the CDE report, the AEP must issue a separate ISP that states expected measurable improvement, lists all services/providers, aligns services, documents individual characteristics affecting intervention, sets priorities, and includes ongoing monitoring plans tied to the CDE.

Documentation Required
Maintain BT qualification documentation and BA supervision records
Maintain documented evidence of BT qualifications: either RBT credential or documented training meeting the non‑RBT pathway (age ≥18, minimum high school diploma or equivalent, ≥4 hours ASD training, and ≥40 hours AI training toward RBT). Also retain records of BA supervision hours per BT per individual.
If non‑RBT, documentation must include age, education level, ≥4 hours ASD training, and ≥40 hours AI training toward RBT requirements.
BA supervision records must show at least one hour of case supervision for every 10 hours of BT intervention per individual.

Prior Authorization
Obtain referral to AEP and complete ISP to progress to AI services
Ensure a referral from a physician or other licensed practitioner to an Autism Evaluation Practitioner (AEP) and completion of the Integrated Service Plan (ISP) after diagnosis; lack of the referral or failure to complete the ISP may prevent progression to covered AI services.
Referral initiates Stage 1: AEP makes diagnosis and develops the ISP.
ISP must include required content and link to CDE findings to support progression to Stage 2/3 services.

Denial Risk
Provide and document BA supervision at 1:10 ratio
Provide and document required Behavior Analyst (BA) supervision: at least one hour of case supervision from the BA for every 10 hours of intervention the Behavioral Technician (BT) delivers to an individual; failure to provide this supervision risks noncompliance.
Supervision ratio requirement: 1 hour BA supervision per 10 hours BT intervention per individual.
Noncompliance with supervision requirements may affect coverage and practitioner compliance.

MethodsAssessment incorporates multiple methods and informants, including direct observation, measurement and recording of behavior, interviews, rating scales, and input from caregivers and professionals.

OutputResults form the basis for the Autism Intervention Treatment Plan (AITP) which specifies target behaviors and interventions for Stage 3.

Stage 3 AI Services

Scope of servicesStage 3 AI Services are the delivery of behavioral treatment, intervention, and behavior modification services by BAs and BTs in home, clinic, and community-based settings.

Core techniquesIncludes reinforcement (positive/negative), differential reinforcement, stimulus change, schedules of reinforcement, shaping, chaining, discrete trial teaching, verbal behavior training, prompting/fading, and modeling/ imitation training.

Behavior managementAlso includes antecedent methods, procedural packages to prevent/reduce maladaptive behavior, consequential methods (e.g., response cost, time out), extinction procedures, and behavior-change systems such as token systems and PECS.

Behavioral Technician (BT)

RBT pathwayA Behavioral Technician (BT) may be a Registered Behavioral Technician (RBT®) credentialed by the BACB®.

Alternative training pathwayOr a BT may have documented training in Behavior Analysis without RBT credentials and must meet these requirements: age ≥18; minimum high school diploma or equivalent; ≥4 hours ASD-specific training; and ≥40 hours of AI training toward RBT credentialing.

Supervision requirementBTs must receive at least one hour of case supervision from the BA for every 10 hours of intervention the BT renders per individual.