CurrentOptumPolicy N/A

Hawaii Medicaid ABA Treatment Request Cover Page

Cover sheet and intake form for requesting authorization of Applied Behavior Analysis (ABA) services under Hawaii Medicaid (QUEST) through Optum; used by providers to submit supporting clinical documents and prior authorization requests for members receiving ABA.

Policy Summary

PayerOptum

PolicyHawaii Medicaid ABA Treatment Request Cover Page

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage changes)

Effective DateN/A

Next Review DateN/A

Key ActionComplete the cover page and fax to 1-888-541-6691 or submit the authorization request online via Provider Express with supporting clinical documents.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1-888-541-6691fax number to submit form

Provider Expressonline submission option

Hawaii QUEST ABArelated program/webpage

Form Required Information and Supporting Clinical Documentation

Form fields / required supporting information

Form fields to be completed and supported by attached clinical documents; refer to the HI Medicaid ABA Policy for full network and clinical criteria.

ALL of the following

Current primary DSM-5 diagnosis and code number (as reflected in attached supporting clinical documents).
Who gave the diagnosis (clinician name/credentials).
Date diagnosis was given.
Indication whether the diagnosis was the result of a Comprehensive Diagnostic Evaluation (CDE).

Policy Summary

PayerOptum

PolicyHawaii Medicaid ABA Treatment Request Cover Page

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage changes)

Effective DateN/A

Next Review DateN/A

Key ActionComplete the cover page and fax to 1-888-541-6691 or submit the authorization request online via Provider Express with supporting clinical documents.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Other medical or mental health diagnoses (if applicable).

Current medications.

Location of services (select).

Other services the child receives (e.g., speech, occupational therapy, outpatient counseling).

School enrollment status; if enrolled, type of school and hours per week in school.

Hours per week of other therapeutic activities outside of school.

Coordination of care with other providers; include documentation in attached supporting clinical documents if yes.

Length of time (years) member has been in ABA services.

Duration member has been receiving services at this intensity (hours/week or description).

Proposed start date of authorization/notification.

Severity of communication deficit (select).

Severity of social deficit (select).

Severity of behavior deficits (select).

Severity of destructive or maladaptive behaviors (select).

Are caregivers involved in treatment (select) and brief description of caregiver involvement (e.g., separate training sessions, shadowing in sessions).

Number of hours per week caregivers are involved in sessions or caregiver training (select).

How caregivers are rated regarding proficiency with ABA techniques and working with the individual (select).

Provider signature attesting that information provided in this prior authorization request is true and accurate.

Attach supporting clinical documents that reflect and substantiate all answers above; for full network and clinical criteria, refer to the HI Medicaid ABA Policy on Provider Express (Hawaii QUEST ABA Program).

How to Submit the ABA Treatment Request Cover Page

Prior Authorization

Submission Instructions

Complete the Hawaii Medicaid ABA Treatment Request Cover Page and submit with supporting clinical documents. Fax the completed form and attachments to 1-888-541-6691. Alternatively, providers may submit the authorization request online through Provider Express. Information submitted will be protected in accordance with HIPAA and other applicable confidentiality regulations.

Fax submissions: 1-888-541-6691
Online submissions: Provider Express (use the authorization request workflow)
Include supporting clinical documents with the cover page
Ensure all provider and member fields on the cover page are completed (provider name, TIN, servicing address, phone, fax, designated case supervisor name/credentials/contact/email/availability; member name, DOB, address, member ID)
Text fields on the form will expand as needed; you may copy and paste into fields

Key Contact and Case Supervisor Information

Designated Case Supervisor — required contact details

Name and CredentialsDesignated Case Supervisor Name and Credentials (as entered on form)

Contact NumberDesignated Case Supervisor Contact # (phone number field on form)

EmailDesignated Case Supervisor Email (email field on form)

Availability for Call BackDesignated Case Supervisor availability for call back (days and times) — requested on form

Submission InstructionInclude supervisor contact details on the cover page submitted by fax to 1-888-541-6691 or via Provider Express

Privacy NoteInformation provided (including supervisor contact) will be protected in accordance with HIPAA and confidentiality regulations