Kansas Medicaid prior authorization required for CCTS/IIS

For Kansas Medicaid CCTS and IIS (ABA) services, prior authorization is required and will be reviewed after all requested documentation has been submitted; medical necessity is determined on a case-by-case basis.

• Applies to Consultative Clinical and Therapeutic Services (CCTS) and Intensive Individual Support Services (IIS).
• Submit all requested documentation to initiate prior authorization review.

Ohio Medicaid: secure single case agreement if not enrolled

If an Ohio Medicaid ABA provider is not enrolled with Medicaid, obtain a single case agreement before providing services; review Ohio Administrative Code for eligible practitioner lists and any applicable prior authorization requirements.

• Single case agreement required when provider is not enrolled with Ohio Medicaid.
• Follow Ohio Administrative Code for prior authorization rules and eligible practitioner lists.

Ohio Medicaid prior authorization / single case agreement requirement

Ohio Medicaid may require prior authorization and/or a single case agreement for providers not enrolled with Medicaid; verify enrollment status and secure required authorizations per Ohio Administrative Code prior to delivering ABA services.

• Confirm provider enrollment with Ohio Medicaid.
• If not enrolled, arrange single case agreement and any applicable prior authorization.

Utilization review may be requested no more than every 12 months

Insurers may request utilization review of autism treatment not more than once every 12 months (unless a more frequent review is mutually agreed), which may affect continued authorization and require provider submission of supporting records.

• Insurer bears cost of obtaining any review.
• Providers must furnish medical records, clinical notes, or other necessary data upon request to substantiate medical necessity and improved clinical status.

Provide detailed treatment plan and clinical documentation on request

Required clinical documentation and treatment plan elements must be provided upon insurer request to support initiation and continued ABA services, including diagnosis, treatment goals, and measures of progress.

• Treatment plan should include diagnosis, proposed treatment type/frequency/duration, anticipated outcomes/goals, and update frequency.
• Goals must be specific, directly observed, continually measured, and address ASD characteristics.
• For referrals (e.g., NY Medicaid) include patient age, diagnosis, date of initial diagnosis, co-morbid diagnoses, symptom severity/level of support, statement of need for ABA, and DSM-5 diagnostic checklist when applicable.

Kansas: document diagnosis with validated tools and qualified diagnostician

Kansas requires diagnostic documentation by a qualified Kansas BSRB clinical psychologist or qualified physician using a comprehensive diagnostic evaluation and a validated ASD diagnostic assessment tool (e.g., ADOS or CARS); documentation of additional ASD diagnostic training may be subject to Optum audit.

• Member must be age 20 or under for Kansas Medicaid eligibility.
• Recommended diagnostic components include cognitive evaluation (e.g., CAT/CLAMS, MSEL, BSID) and an adaptive behavior measure (e.g., ABAS or VABS).
• Once diagnosed per policy, re-evaluation is not required and there is no time limit to start treatment.

Ohio Medicaid telehealth: verify enrollment and authorization requirements

When providing ABA to Ohio Medicaid members via telehealth, follow Ohio Medicaid telehealth guidance and ensure provider enrollment or a single case agreement is in place; verify and comply with any applicable prior authorization requirements.

• ABA is available through telehealth under current Ohio Medicaid guidelines.
• If provider is not enrolled with Medicaid, a single case agreement would be needed.

Do not authorize ABA for specified excluded program purposes or duplicate services

Do not seek authorization for ABA services when the claimed purpose is an excluded program purpose (speech therapy, occupational therapy, vocational rehabilitation, supportive respite, recreational therapy, orientation and mobility), when services are provided in a PRTF/hospital setting, or when services duplicate those already provided in another setting.

• Services specifically listed as non-authorizable include: speech therapy; occupational therapy; vocational rehabilitation; supportive respite care; recreational therapy; orientation and mobility.
• Services provided in a PRTF/hospital setting or duplicated by another source/setting will not be authorized.

Authorize additional hours beyond mandate only with medical necessity

Additional ABA hours beyond state-mandated weekly limits (e.g., Maryland mandates up to 25 hrs/wk for ages 18 months–5 years and up to 10 hrs/wk for ages 6–18 years) will only be authorized if determined medically necessary and appropriate; Optum will review requests for additional treatment using medical necessity guidelines.

• Maryland: services meeting initiation/continuation criteria will not be denied solely on number of hours up to the specified amounts; additional hours require medical necessity determination.
• After exhausting mandated benefits, Optum reviews additional treatment requests under its standard medical necessity policy.

Risk of denial if Ohio Medicaid provider enrollment or single case agreement not in place

If a provider is not enrolled with Ohio Medicaid, lack of enrollment may trigger denial risk unless a single case agreement is executed and any required prior authorization is obtained; verify enrollment status before billing or providing services.

• Single case agreement is required for non-enrolled providers to deliver ABA to Ohio Medicaid members.
• Failure to secure required agreements/authorizations may risk denial of payment.