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    v1.0.28
    OpenPayerPolicy UpdatesPsychiatry/Behavioral HealthNew Mexico HCA Stage 2 AI Coverage | OpenPayer
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    CurrentNew Mexico Health Care AuthorityPolicy N/A

    Stage 2 Behavior Analytic Assessment and Autism Intervention Treatment Plan (AITP) Coverage Criteria

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    Defines practitioner requirements, assessment components, and service descriptions for Stage 2 Applied Intervention (AI) services for individuals with Autism Spectrum Disorder under New Mexico's Medicaid State Plan; affects behavior analysts and related providers seeking reimbursement for Stage 2 services.

    Policy Summary
    PayerNew Mexico Health Care Authority
    PolicyStage 2 Behavior Analytic Assessment and Autism Intervention Treatment Plan (AITP) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateOct 1, 2024
    Next Review DateN/A
    Key ActionBehavior Analysts must conduct a Stage 2 Behavior Analytic Assessment and develop an AITP that documents target behaviors, measurement methods, and assigned intervention staff to be eligible for reimbursement.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Stage 2service level described
    AITP requiredtreatment plan produced from assessment
    BCBA requiredpractitioner credential explicitly listed

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    Multiple
    assessment methods

    Coverage Criteria for Stage 2 Assessment and AITP

    Stage 2 Assessment and AITP Coverage Criteria

    Covered when ALL of the following are met:

    Provider qualifications: An AP must meet specified practitioner requirements (e.g., BCBA or BCBA-D) and attest to meeting provider criteria, including advanced training in differential diagnosis of ASD; documentation must be provided upon request.

    See practitioner requirements in Stage 2 AI Services Practitioner Requirements.

    Referral/ISP basis: There is completion of an Individualized Service Plan (ISP) that includes a recommendation for AI Stage 2 services prior to conducting the Stage 2 Behavior Analytic Assessment.

    Stage 2 assessment follows ISP recommendation.

    Behavior Analytic Assessment content: A Behavior Analytic Assessment specific to Stage 2 is conducted using developmentally appropriate strategies, identifies strengths and weaknesses across domains, and uses multiple methods and informants including direct observation, measurement and recording, interviews, rating scales, and validity measures.

    Direct observation, measurement, and recording serve as the primary basis for identifying pre-treatment levels, discharge goals, and evaluation of response to the AITP.

    AITP requirements: An Autism Intervention Treatment Plan (AITP) is developed from the assessment and must identify all target behaviors to be addressed, specify how goals will be measured, assign intervention staff roles (e.g., BCaBA, BT, QABA, BA), and include family/caregiver training goals when appropriate.

    AITP guides whether Focused or Comprehensive AI approaches are used based on assessment findings.

    The policy text does not list any specific service exclusions for Stage 2 Applied Intervention (AI) services. Review of the provided document found no explicit exclusions stated for Behavior Analytic Assessment or the resulting Autism Intervention Treatment Plan (AITP).

    The provided policy language does not identify any conditions, populations, or service circumstances that are explicitly designated as not medically necessary for Stage 2 Behavior Analytic Assessment or AITP services.

    Provider Eligibility, Documentation, and Billing Implications

    Prior Authorization

    Meet practitioner requirements (BCBA/BCBA‑D) for reimbursement

    An AP must meet the practitioner requirements (e.g., BCBA or BCBA‑D) to have an approved MAD PPA and be eligible for reimbursement for provision of a Stage 2 Behavior Analytic Assessment and completion of the AITP.

    Step Therapy

    Conduct Stage 2 Behavior Analytic Assessment to select treatment intensity

    Following an ISP that recommends Stage 2 services, a Behavior Analyst (BA) must conduct a Stage 2 Behavior Analytic Assessment to determine need for skill acquisition and behavior reduction and then develop an Autism Intervention Treatment Plan (AITP) specifying goals and intervention services; treatment intensity and approach (Focused vs Comprehensive) are selected based on assessment results.

    Stage 2 / Applied Intervention (AI) Services - Level of Care

    Behavior Analytic Assessment and Treatment Planning Elements

    Behavior Analytic Assessment and Treatment Planning

    Assessment and treatment planning elements for Applied Intervention (AI) Stage 2

    Assessment methods: Use multiple methods and informants (direct observation, measurement, interviews, rating scales, validity measures) to assess skill deficits and behavioral excesses and their impact on functioning.

    Direct observation, measurement, and recording are defining characteristics and primary basis for pre-treatment levels and discharge goals.

    Goal selection and measurement: The Behavior Analyst must select intervention goals after the assessment and determine how each goal will be measured; the AITP must identify target behaviors and assign responsibility to appropriate intervention staff (BCaBA, BT, QABA, BA).
    Treatment approach selection: Treatment approach may be Focused or Comprehensive depending on variables such as number and complexity of behavioral targets, individual's response to protocols, age, intensity and frequency needs.

    Behavior Analytic Interventions (Focused or Comprehensive)

    Behavior Analytic interventions — Focused or Comprehensive

    Focused vs Comprehensive determination: Selection of Focused or Comprehensive AI approaches is based on variables including the number of behavioral targets, the specific aspects of those behaviors, and the individual's response to treatment protocols; differences relate to age, intensity, duration, and frequency.

    Both approaches exist on a continuum and may be combined as appropriate.

    Key Definitions

    Focused AI services vs Comprehensive AI approach
    Category definitionsFocused AI services: target a limited set of behavioral goals; Comprehensive AI approach: addresses a broader range of treatment goals — these categories differ by age, intensity, duration, and frequency of services.
    Determinants of approachSelection between Focused and Comprehensive is based on variables including number of behavioral targets, specific behavioral features, and individual response to treatment protocols.
    Service continuumThe two approaches exist on a continuum and may be combined; treatment intensity, duration, and frequency vary across the continuum.
    Implementation implicationBA chooses approach after Behavior Analytic Assessment based on assessed needs and response to protocols.
    Autism Intervention Treatment Plan (AITP)
    Definition

    Background on Stage 2 Applied Intervention

    Stage 2 Applied Intervention (AI) services are specialized behavior-analytic assessments and interventions for individuals with Autism Spectrum Disorder. The Behavior Analytic Assessment uses developmentally appropriate methods and multiple informants (with direct observation as the primary source) to identify strengths and deficits across domains. An individualized Autism Intervention Treatment Plan (AITP) is developed from the assessment and must specify target behaviors, measurement methods, assignment of intervention staff, and when appropriate, family/caregiver training; the assessment also guides selection of a Focused versus Comprehensive treatment approach based on factors such as number and complexity of targets, age, and response to protocols.

    Visit Limits and Frequency/Duration

    Visit limits
    Visit limits statedNo specific visit limits or frequency/duration caps are specified in the provided text.
    Frequency/duration determinationIntensity, duration, and frequency of treatment are determined based on assessment variables such as number and complexity of behavioral targets and individual response to protocols.
    Continuum of careFocused and Comprehensive approaches exist on a continuum; therefore visit needs may vary and are individualized rather than prespecified.
    Policy Summary
    PayerNew Mexico Health Care Authority
    PolicyStage 2 Behavior Analytic Assessment and Autism Intervention Treatment Plan (AITP) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateOct 1, 2024
    Next Review DateN/A
    Key ActionBehavior Analysts must conduct a Stage 2 Behavior Analytic Assessment and develop an AITP that documents target behaviors, measurement methods, and assigned intervention staff to be eligible for reimbursement.
    SourceLink
    On This Page
    Coverage Criteria for Stage 2 Assessment and AITPProvider Eligibility, Documentation, and Billing ImplicationsStage 2 / Applied Intervention (AI) Services - Level of CareBehavior Analytic Assessment and Treatment Planning ElementsBehavior Analytic Interventions (Focused or Comprehensive)Key DefinitionsBackground on Stage 2 Applied InterventionVisit Limits and Frequency/Duration
    Documentation Required

    Sign attestation and provide qualifying documentation when requested

    Providers must sign an attestation form affirming that all provider criteria have been and will continue to be met and, when requested, provide documentation substantiating training, experience, licensure and/or certification, including advanced training in differential diagnosis of ASD.

    Documentation Required

    Document Assessment and AITP elements (goals, targets, measurement, roles)

    The Behavior Analytic Assessment and resulting AITP must document strengths and weaknesses across domains, identify all target behaviors to be addressed, specify measurement methods, assign roles (e.g., BCaBA, BT, QABA, BA), and include caregiver/family training goals when appropriate; direct observation, measurement, and recording must be used as primary basis for pre‑treatment levels, discharge goals, and evaluation of response.

    Denial Risk

    Non‑eligibility for listed practitioner credentials precludes reimbursement

    Failure to meet the listed practitioner eligibility requirements (for example, not being a BCBA or BCBA‑D) will preclude approval for reimbursement for Stage 2 services.

    An individualized Autism Intervention Treatment Plan (AITP) developed from the Stage 2 Behavior Analytic Assessment that specifies goals, target behaviors, measurement methods, assigned intervention staff, and when appropriate, family/caregiver training goals.
    BasisAITP is based on a Behavior Analytic Assessment using multiple methods and informants (direct observation, interviews, rating scales, validity measures) to identify strengths and weaknesses across domains.
    Content requirementsAITP must identify all target behaviors to be addressed and specify how goals will be measured and which staff (BCaBA, BT, QABA, BA) are assigned to each target.
    Family involvementWhen appropriate, the AITP includes goals for working with family or caregivers to assist with acquisition, maintenance, and generalization of functional skills.