CurrentNorth Dakota Department of Health & Human ServicesPolicy N/A

North Dakota Medicaid Policy and Procedures for the Autism Applied Behavior Analysis Service

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This policy governs North Dakota Medicaid eligibility, authorization, medical necessity review, provider qualifications, care planning, documentation, oversight, skills training, monitoring, and service delivery for children receiving Autism Applied Behavior Analysis services.

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyAutism Applied Behavior Analysis Services

Policy CodePolicy N/A

Change TypeRoutine revision

Effective DateFebruary 1, 2025

Next Review DateN/A

Key ActionSubmit a web-based Service Authorization request twice per year, at the annual review and 180-day update, with the required care plan and approval letter attached.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Under 21Maximum eligibility age

12 months

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CurrentNorth Dakota Department of Health & Human ServicesPolicy N/A

North Dakota Medicaid Policy and Procedures for the Autism Applied Behavior Analysis Service

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Sign up for all North Dakota Department of Health & Human Services policy alerts

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Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyAutism Applied Behavior Analysis Services

Policy CodePolicy N/A

Change TypeRoutine revision

Effective DateFebruary 1, 2025

Next Review DateN/A

Key ActionSubmit a web-based Service Authorization request twice per year, at the annual review and 180-day update, with the required care plan and approval letter attached.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Under 21Maximum eligibility age

12 months

180 daysCare plan update interval

MonthlyProgress-review meeting frequency

1/daySpeech and ABA billing limit

Eligibility, Continuation, and Exclusions

Initial eligibility

A child is considered for Autism ABA services when all of the following are met.

Eligibility

Age: Child is under 21 years of ageunder 21
Medicaid eligibility: Child is ND Medicaid eligible on the dates of serviceeligible on dates of service
Diagnosis: Child has an autism spectrum disorder diagnosis from the primary care provider or a licensed medical care provider qualified to diagnose autism spectrum disorderdocumented ASD diagnosis
Health Tracks screening: Child has an annual North Dakota Health Tracks/EPSDT screening completed at a public health unit or by a primary care provider, within six months of the date considered eligible, submitted with the request, and the recommendation supports and recommends Autism ABA servicesscreening within 6 months of eligibility consideration

Annual continuation and medical necessity

Continued annual approval requires all of the following.

Annual medical necessity and continuation

Health Tracks review: A Health Tracks screening or Well Child Check is completed, lists the autism diagnosis, and includes the primary care physician recommendation for ABA servicescompleted annually; may be completed within 6 months before the due date
The screening must be sent to the department for review
Updated care plan: The care plan is updated and supports continued medical necessityannual update
A prior approval letter is generated at the time of review
Six-month progress review: Progress reports and assessments are reviewed so services can be adjusted to the child's needs

Ongoing treatment and monitoring

The care plan and monitoring process must include all applicable elements.

Ongoing treatment requirements

Measurable goals: Goals are consistent with assessment findings, achievable during the authorization period, prioritized, and supported by measurable short-term objectives when neededmeasurable objectives
Longer-term goals should be broken into short-term objectives
Caregiver involvement: The plan includes caregiver training and support goals, techniques taught, caregiver progress, and caregiver participation in treatment decisionsdocumented in annual and 180-day plans
Monitoring: Services are furnished according to the care plan, show positive progress, use standardized data collection, and reflect changes in the child's needs

Individualized treatment domains

When the need is identified, the care plan may address the following functional skill domains.

Treatment skill domains

Behavioral and adaptive skills: Replacement of inappropriate behaviors; adaptive behavior; self-care; self-monitoring; sequencing; routines; and independenceas needed
Motor and cognitive skills: Fine and gross motor skills, play-related cognitive skills, and academic-related cognitive skillsas needed
Communication and social skills: Functional communication; expressive or receptive language; nonverbal or augmentative communication; social initiation; reciprocal exchange; imitation; and play with peers or siblingsas needed

Punishment procedures that involve adding or removing a stimulus will, in most cases, be denied.

A child is not eligible for consideration for ND Medicaid Autism ABA services unless the child is under 21, ND Medicaid eligible on the dates of service, has a documented autism spectrum disorder diagnosis from a qualified provider, and has a current North Dakota Health Tracks/EPSDT screening completed within six months of the eligibility consideration date. The screening must accompany the request and recommend Autism ABA services.

ND Medicaid does not pay for program services or service components that are unproven, experimental, cosmetic, or research in nature.

Services are excluded when they do not relate to the child's diagnosis, symptoms, functional limitations, or medical history.

Services intended solely to prepare the child for paid or unpaid employment are excluded, including vocational equipment and uniforms.

Services that are solely educational, vocational, recreational, or social are excluded from payment.

ND Medicaid does not pay for respite, childcare, or other custodial services that are not coverable within the preventive services benefit category.

Services that duplicate other State Plan services are excluded from payment.

Authorization, Documentation, and Payment Risks

Prior Authorization

Annual Prior Approval Required

Annual ND Medicaid approval is required for Autism ABA services. Approval covers a 12-month period, and annual medical-necessity review requires an updated care plan and Health Tracks/EPSDT screening submitted to ND Medicaid.

Complete the Health Tracks screening/Well Child Check every 12 months; it may be completed within six months before the due date.
The screening must list the autism diagnosis and PCP recommendation for ABA services.
Obtain the prior approval letter generated through the annual review before continuing services.

Prior Authorization

Twice-Yearly Authorization Requests

Submit a web-based Service Authorization request twice per year: once for the annual authorization and again for the 180-day update.

Maintain an annual care plan.
Update the care plan every 180 days to document continued medical necessity and caregiver training progress.

Autism ABA Services Overview

Autism Applied Behavior Analysis (ABA) services support eligible children with autism spectrum disorder through comprehensive assessment, individualized behavioral treatment, caregiver training, monitoring, referral, and follow-up. Treatment is based on evidence-informed behavioral interventions and measurable functional goals tied to the child's assessed needs. Services may be provided in the home, community, provider facility, or school when approved through an IEP or other educational plan.

Key Terms

Autism ABA service

Defined serviceAssistance provided to a qualifying individual with an autism spectrum disorder (ASD) diagnosis.

Included componentsOversight supporting comprehensive assessment, care plan development, referral, monitoring and follow-up, and skills training for qualifying individuals and their caregivers.

Service locationsServices can occur within the home, community, or a provider's facility.

Skills Training

Defined serviceA direct service designed to assist a child in acquiring skills identified in the care plan.

Primary focusThe service focuses on working in environments to promote the participant's competence and positive behaviors.

Autism ABA Medical Necessity

Autism ABA medical necessity

Autism ABA is covered for an eligible child when eligibility requirements are met and ongoing medical necessity is supported by annual review, six-month progress review, and updated care planning.

ABA eligibility and continuation

Clinical foundation: A documented ASD diagnosis, Health Tracks/EPSDT screening, comprehensive assessment, and evidence-based functional assessment support treatmentcurrent documentation
Individualized treatment: The care plan contains measurable goals, target behaviors, individualized interventions, caregiver objectives, treatment locations, requested hours, and unit justificationspecified in care plan

Covered ABA Components

Applied Behavior Analysis skills training

Skills training is covered when all of the following requirements are met.

Skills Training: Direct skills training is provided for the child's care plan goals, uses evidence-based behavioral intervention methods directed by Service Oversight, trains caregivers to implement interventions across multiple settings, and includes at least monthly review with the Service Oversight practitioner and caregivermonthly review

Documentation must include who was present, time, location, event, and goal data

ABA service oversight

ABA service oversight is covered when all of the following functions are provided as applicable.

Service Oversight includes comprehensive assessment and reassessment, care plan development and revision, referral and linkage, monitoring, follow-up, progress review, and necessary care plan or service adjustmentsreassessment at 180 days; monthly skills trainer and caregiver meetings

Authorization Periods and Service Frequency

Autism ABA services

Approval periodApproval for Autism ABA services is issued for a twelve-month period.

Review requirementAnnual review of medical necessity is required.

Annual approval basisAnnual approval requires an updated care plan and a Health Tracks screening; a prior approval letter is generated at the time of review.

Autism ABA services

Care plan updateThe care plan must be updated every 180 days to ensure the child continues to meet medical necessity criteria.

Progress and reassessmentServices are reviewed through a six-month progress period, and reassessment must be completed at 180 days.

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyAutism Applied Behavior Analysis Services

Policy CodePolicy N/A

Change TypeRoutine revision

Effective DateFebruary 1, 2025

Next Review DateN/A

Key ActionSubmit a web-based Service Authorization request twice per year, at the annual review and 180-day update, with the required care plan and approval letter attached.

SourceLink

On This Page

6-month progress period

timely monitoring; treatment change within 4–6 weeks when there is no improvement

Monthly meetings with the skills trainer and caregiver are required

Engagement and cooperation: Developmentally appropriate play; attending; responding to environmental cues; flexibility; cooperation with instructions; following routines; and following peer instructionsas needed

Documentation Required

Service Authorization Submission

Attach the required supporting materials to each Service Authorization request so ND Medicaid can evaluate the requested Autism ABA services.

Attach the current care plan.
Attach the yearly ND Medicaid letter of approval.
Include the requested service information, including service codes, hours per week, and justification for units.

Documentation Required

Required Plan of Care Contents

The plan of care must be sufficiently detailed to support the requested services and include mechanisms to monitor effectiveness. Include recipient, family, medical, educational, behavioral, treatment, caregiver, and practitioner information.

Identify the recipient by name, age, date of service, time/duration, family composition, residency, and legal responsible party.
Include medical and family history; all-axis diagnosis; treating practitioner names; immunization record; recent medical appointments, if available; current health status; medical needs; and medications used to ameliorate behaviors, including dosages if available.
Include the recipient's history/background, education level and setting, placement history, presenting concerns, and work or employment status.
Include the functional assessment, standard ABA behavioral definitions, and graphs showing frequency, intensity, latency, or duration of behavioral excesses and deficits.
Include treatment goals and primary plan of action, progress and barriers, individualized child goals with performance criteria, individualized parent goals, caregiver feedback and participation, and a caregiver checklist/training plan.
Include the BCBA signature and date of signature.

Documentation Required

Assessment and Care Plan Detail

Base the assessment and care plan on a comprehensive history, information from relevant sources, and an evidence-based functional assessment using indirect and direct assessment methods. The plan must translate findings into measurable, prioritized, individualized treatment.

Identify and describe target behaviors, establish baseline measurements, graph starting points and progress, and connect findings to autism symptoms.
Specify measurable goals, short-term objectives when goals extend beyond an authorization period, assessment methods and frequency, protocols, locations, caregiver goals, and requested hours by service code with unit justification.
Tie each intervention to the protocol and behavior being treated; target behaviors should not be vocational or educational in purpose.
Include aggressive or inappropriate behavior goals, caregiver training and support, and the majority of requested hours provided by an RBT when applicable.

Unsupported block type: documentation

Documentation Required

Progress and Encounter Documentation

Document each skills-training encounter and use standardized, readable data to support monitoring and timely treatment changes. Records must show that services were delivered as authorized and in accordance with the care plan.

Record who was present or received the service, time and duration, location, the event or service provided, and goal-related data.
Use standardized data-collection protocols for all behaviors under treatment; graphs must be easily readable.
Hold monthly meetings with the skills trainer and caregiver to review goal progress and determine whether the care plan needs changes.
Monitor implementation, positive progress, and changes in the child's needs or status; make adjustments when there is no improvement for approximately 4–6 weeks.
Notify ND Medicaid of updates including institutional placement or discharge, and transmit protected health information in accordance with HIPAA.

Denial Risk

Eligibility Failure May Result in Ineligibility

Children who do not meet all eligibility criteria are not eligible for consideration for Autism ABA services through ND Medicaid. Children who meet the criteria receive an ND Medicaid approval letter for the provider.

The child must be under age 21 and ND Medicaid eligible on the dates of service.
A qualified provider must diagnose autism spectrum disorder.
A current Health Tracks/EPSDT screening, within six months of the eligibility date, must accompany the approval packet and support and recommend Autism ABA services.

Denial Risk

Missing Annual or Semiannual Review

Authorization may not continue if the required annual approval, care-plan update, Health Tracks screening, or 180-day review is missing. Maintain each review and submit the required documentation before the authorization period expires.

Annual approval requires an updated care plan and Health Tracks screening.
The care plan must be updated every 180 days with progress, goals, caregiver implementation, and changes to interventions.

Denial Risk

Insufficient Assessment or Treatment Plan

Incomplete clinical support can result in denial or reduction of requested services. Assessments and treatment plans must establish the child's needs, measurable baseline and goals, individualized interventions, and service justification.

Include direct and indirect functional assessment, target-behavior definitions, baseline and progress graphs, and a connection to autism-related symptoms.
Ensure goals are measurable, prioritized, assessment-linked, and achievable during the authorization period.
Document protocols, frequency and methods of measurement, locations, caregiver goals, requested hours, and unit justification.

Denial Risk

Punishment-Based Intervention

Punishment procedures, including adding or removing a stimulus, will in most cases be denied. Use interventions specifically tied to an evidence-based protocol and the behavior targeted for treatment.

Document functional assessment findings and positive, individualized interventions.
Do not rely on punishment-based procedures as the treatment approach.

Denial Risk

Qualified and Enrolled Providers Required

ND Medicaid payment is made only to providers actively enrolled in ND Medicaid and meeting the applicable qualifications. Ensure service oversight and skills-training staff maintain required licenses, certifications, supervision, and credentialing.

Service Oversight must be provided by an eligible licensed BCBA, BCBA-D, registered behavior analyst, or licensed clinical psychologist.
Skills trainers must hold an accepted credential or license; individuals enrolling with an approved qualifying degree must become an RBT or BCAT within six months of enrollment.
Skills training must be supervised by a qualified Service Oversight practitioner operating within North Dakota scope-of-practice laws.
Agencies and schools must train staff for unsafe, crisis, and unstable situations and ensure Service Oversight staff meet the required qualifications.
Submit institution name, degree title, completed transcript, and side-by-side degree comparison when requesting case-by-case approval of an additional degree.

Denial Risk

Demonstrate Progress and Update Care

Monitor whether services are implemented as planned and produce positive progress. Failure to collect data, address barriers, or update the care plan when the child's needs change creates a risk of denial or interruption of services.

Collect data for every behavior under treatment using standardized protocols and readable graphs.
Make treatment or service-arrangement changes in a timely manner, particularly after approximately 4–6 weeks without improvement.
Document monthly skills-trainer and caregiver progress reviews and necessary care-plan adjustments.
Ensure the care plan reflects changes in the child's needs or status.

Denial Risk

Unproven or Experimental Services

ND Medicaid will not pay for program services or components that are unproven, experimental, cosmetic, or research in nature.

Use evidence-based interventions supported by the assessment and care plan.

Denial Risk

Lack of Clinical Relationship

Payment is not available for services unrelated to the child's diagnosis, symptoms, functional limitations, or medical history. Tie every requested and delivered service to documented clinical need.

Document the clinical relationship between the service, assessment findings, autism-related needs, and treatment goals.

Denial Risk

Employment or Vocational Preparation

ND Medicaid will not pay for services intended solely to prepare a child for paid or unpaid employment, including vocational equipment or uniforms.

Do not characterize solely vocational preparation or vocational equipment as covered Autism ABA service.

Denial Risk

Non-Therapeutic Services

ND Medicaid will not pay for services that are solely educational, vocational, recreational, or social. Services must directly benefit the child by addressing care-plan goals through covered clinical interventions.

Document the therapeutic purpose, individualized goal, and evidence-based intervention for each service.

Denial Risk

Noncovered Custodial Services

ND Medicaid will not pay for services that are not coverable under the preventive-services benefit category, including respite, childcare, or other custodial services.

Do not bill custodial supervision, respite, or childcare as Autism ABA service.

Denial Risk

Duplicate State Plan Services

ND Medicaid will not pay for services that duplicate other State Plan services. Coordinate services and document distinct covered purposes to avoid duplicate billing.

Review other State Plan services before requesting or billing Autism ABA.

Billing Rule

One Speech or ABA Service Per Day

If one agency provides both Speech Services and ABA services to an individual, only one service may be billed per day.

Coordinate scheduling and billing so Speech Services and ABA services are not both billed on the same day by the same agency.

Intervention and caregiver supportIt trains caregivers to implement interventions across multiple settings and provides hands-on, evidence-based behavioral intervention as directed by Service Oversight practitioners.

Functional assessment

Assessment typeAn evidence-based functional assessment that includes indirect and direct assessments of the child's needs.

Required assessment elementsThe assessment includes identified target behaviors, descriptions of those behaviors, and established baseline measurements.

DocumentationThe assessment identifies specific individual interventions, includes graphs of starting-point and progress data, and provides narrative findings tied to autism symptoms.

Service Oversight

Responsible practitionerThe practitioner responsible for comprehensive assessment and periodic reassessment of the child's needs.

Care planning roleThe practitioner develops and periodically revises the specific care plan based on information collected through assessment.

Oversight responsibilitiesThe practitioner provides supervision, monitoring, follow-up, and direction of skills training.

Progress and adjustment:

Progress data are collected and reviewed, services show positive progress, and the care plan or service arrangements are adjusted when needs change or there is no improvement

data review; timely changes after 4–6 weeks without improvement

The oversight practitioner must notify ND Medicaid of institutional placement and discharge from the service

Required review contentThe update must address problems being worked on, goals being accomplished or addressed, caregiver intervention changes, target-behavior updates, measurable treatment-goal updates, improvements, and weekly service hours.

Skills training and service oversight

Meeting frequencyThe skills trainer and caregiver must meet with the Service Oversight practitioner at least monthly.

Meeting purposeMeetings are for reviewing progress on formal training objectives and reviewing the need for changes to the care plan.

DocumentationDocumentation must include who was present, the time, where the meeting occurred, the event, and goal data.

Speech services and ABA services provided by the same agency

Applies whenOne agency provides both Speech Services and ABA services to an individual.

Billing limitationOnly one service may be billed per day.

Billing periodThe limitation applies on a per-day basis.