Applied Behavior Analysis (ABA) — New Mexico Supplemental Clinical Criteria
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State-specific supplemental clinical criteria governing medical necessity, provider requirements, prior authorization, and service staging for ABA services under New Mexico Medicaid; applies to members of Optum-managed behavioral health plans in the state. Affects providers (AEPs, BAs, BCaBAs, BTs, SCPs) and families seeking ABA services.
No material clinical or coverage changes in this revision.
Coverage Criteria for ABA Services
Medical Necessity Eligibility
ABA services are medically necessary when the member meets ONE of the following two categories:
From ABA Coverage Criteria
Service Stages and Requirements
Service staging and required actions for each stage:
Stage One requirements (AEP, CDE, ISP)
Stage Two components: assessment, goal selection, measurement
Stage Three treatment and supervision
Stage 3 Medical Necessity and Service Criteria
Covered when ALL of the following are met for Stage 3 ABA services:
Admission and prior authorization requirements
Model appropriateness and typical intensity
Dosage individualized per ISP and level of support
Required ABA Treatment Plan elements
Adult recipient coverage criteria
Adult-specific coverage conditions:
Adult access and CDE requirements
Adult diagnostic confirmation and annual requirements
Non-covered activities include any intervention or task that is not designed to accomplish the objectives specified in an approved ABA treatment plan or that is not grounded in the principles and application of Applied Behavior Analysis (ABA). Activities that occur in school settings and have the potential to supplant educational services are excluded. Services that are more appropriately described as another therapy (for example, speech-language therapy, occupational therapy, physical therapy, counseling) are not covered as ABA even if the provider has relevant expertise. Similarly, staff training, certification or licensure activities, or supervision that is characterized as workforce credentialing rather than clinical case supervision are excluded from ABA coverage.
When ABA services are provided under a school's IEP or IFSP, those school-based services do not preclude coverage of medically necessary ABA delivered in other natural settings. School services address educational goals required for a Free and Appropriate Public Education and are not considered a replacement for medically necessary ABA; rather, ABA in non‑educational settings may be provided to support the recipient's ability to access and participate in their educational program.
For adult recipients, a Comprehensive Diagnostic Evaluation (CDE, T1026 TG) is not required unless the AEP determines it is medically warranted. Adults may access Stage 2 services without prior CDE and may proceed to Stage 3 once Stage 2 requirements and an approved treatment plan are met. If at any time the AEP determines a CDE or targeted/risk evaluation is medically necessary, the clinical record must document that medical necessity and the AEP must complete the evaluation and a new ISP as indicated.
Codes, Visit Frequencies, and Authorization Intervals
| T1026 | Comprehensive Diagnostic Evaluation (CDE) / ISP |
| 97151 | Behavior identification assessment by a physician or other qualified health care professional |
| 97152 | Behavior identification supporting code (part of 97151 bundle per doc) |
| 0362T | Targeted/risk evaluation (used collectively with 97151/97152 as '97151' per document) |
| 97156 | Family/caregiver training - for Stage 3 (required units) |
| 97157 | Multiple-family group behavioral treatment (part of Stage 3 required units) |
Provider Requirements, Prior Authorization, and Documentation
Prior Authorization Required
Stage Three (ABA Treatment) Prior Authorization & Continued Service Requirements — Prior authorization to initiate Stage 3 ABA services is required and must be secured initially and every six months thereafter for ongoing Stage 3 services. At each six-month authorization point, the reviewer will assess progress and, with input from the family and the AP's BA, determine whether changes to the ISP or ABA Treatment Plan are needed. Families or APs may request ISP modifications sooner if immediate changes are warranted to preserve the member's health and wellbeing.
- PA required for initial and ongoing Stage 3 ABA services; renew every 6 months
- At each renewal, reviewer assesses progress and need for ISP/treatment plan changes with family and AP BA input
- Family/AP may request ISP modifications prior to 6-month renewal if clinically warranted
Prior Authorization Documentation
Required documentation for initial and ongoing prior authorization for Stage 3 services: The AP must submit the prior authorization request and include the CDE or targeted evaluation and the ISP from the AEP (developed in Stage 1), plus the ABA Treatment Plan (developed in Stage 2). The request should specify the requested treatment model (focused or comprehensive), maximum hours of direct service requested per week, hours of case supervision requested per week (if more than 2 hours per 10 hours of intervention), and hours of clinical management requested per week (if more than 2 hours per 10 hours of intervention). Document hours allocated to other services that appear in the ISP (e.g., early intervention, PT, SLP) to demonstrate feasibility of the requested intensity. If a need for specialty care is identified, documentation of referral and collaboration needs must be included.
- Include CDE or targeted evaluation and ISP from the AEP with the PA request
- Include ABA Treatment Plan from the AP/BA
- Specify treatment model (Focused or Comprehensive) and maximum hours/week
- Document requested case supervision and clinical management hours when exceeding standard ratios
- Document hours allocated to other services in the ISP
- Include documentation of need for collaboration with ABA Specialty Care Provider when applicable
Staged Service Workflow and Timelines
Staged service workflow — Services progress through three stages. Stage 1: AEP completes the Comprehensive Diagnostic Evaluation (CDE) or Targeted/Targeted Risk Evaluation and issues an Integrated Service Plan (ISP). The ISP must be issued within 30–45 calendar days of the CDE completion and the AEP must provide a thorough CDE report within 60 calendar days of completion. Stage 2: The referred AP agency completes a behavior/functional analytic assessment (e.g., 97151/97152/0362T) to determine whether Focused or Comprehensive ABA is appropriate and develops the ABA Treatment Plan. Stage 3: ABA treatment is implemented by BACB-certified BAs/BCaBAs, BAA/mentored BAs, and BTs/RBTs in accordance with the ABA Treatment Plan. For members with an existing ASD diagnosis, a new diagnostic re-evaluation is not required, but an ISP and determination of medical necessity for ABA services are required prior to Stage 3 authorization.
- Stage 1 (AEP): CDE/Targeted or Targeted Risk Evaluation → ISP (ISP issued within 30–45 days; CDE report within 60 days)
- Stage 2 (AP): Behavior/functional assessment (e.g., 97151 series) → ABA Treatment Plan (completed no later than 2 months after 97151)
- Stage 3 (Treatment): Implementation per ABA Treatment Plan by BA/BCaBA/BAA/BT/RBT with required clinical management and supervision
- Existing ASD diagnosis: no diagnostic re-evaluation required but ISP and medical necessity determination required
CDE / ISP Documentation Timeline & Required Content
CDE and ISP documentation timeline and content — The CDE (T1026 TG) must include direct observation and interaction with the recipient, interviews with the recipient and Family Set, and when applicable, input from educational/early intervention providers and other health providers. The CDE must draw from multiple information sources including records review, caregiver and staff interviews, and direct observation. Within 60 calendar days of completion of the CDE, the AEP must issue a thorough report documenting evaluation procedures, results, and case conceptualization. The AEP must also issue an individualized ISP within 30 calendar days (no more than 45 calendar days) after completing the CDE. The ISP must: indicate that ABA services are prescribed when clinically indicated; ensure coordination with other medically necessary services; and specify what each recommended service provider should address and the anticipated range of dosage to guide Stage 2 treatment planning.
- CDE content: direct observation, recipient interview, Family Set interviews, educational/early intervention and other provider records, and multi-domain assessment (developmental, adaptive, social, speech/language, medical/neurological)
- CDE report: issued within 60 calendar days of CDE completion and signed by the AEP
- ISP: individualized and issued within 30 (no more than 45) calendar days after CDE completion; signed by AEP and recipient/legal guardian
- ISP must state when ABA is prescribed, coordinate other services, and indicate provider responsibilities and anticipated dosage ranges to inform Stage 2 planning
ABA Treatment Plan Elements
ABA Treatment Plan required elements — The ABA Treatment Plan must identify all target behaviors and include objective baseline data (directly observed frequency, rate, latency, or duration), standardized assessment scores when available, a comprehensive description of interventions and how many units will be allocated to each target, treatment goals with objective measures for the Prior Authorization period, strategies for generalization and maintenance, family training and engagement strategies, service locations, and measurable discharge criteria. The plan must be completed as expeditiously as possible and no later than two months after completion of the 97151 assessment, be signed by the BA or mentored BA responsible for plan development and oversight, and be time-limited to the Prior Authorization period.
- Complete ABA Treatment Plan no later than 2 months after completion of 97151 and update prior to end of Prior Authorization period
- Include target behaviors, baseline data, standardized assessment scores (e.g., VB-MAPP, ABLLS-R, Vineland, ABAS, PDDBI) as applicable
- Describe interventions for each target, approximate service unit allocation, treatment goals with objective progress measures, generalization/maintenance strategies, family training and engagement, service locations, and discharge criteria
- Signed by the BA/Mentored BA responsible for plan development and oversight
Clinical Background and Scope
Autism Spectrum Disorder (ASD) is a lifelong neurodevelopmental condition characterized by impairments in social communication and restricted, repetitive behaviors. ABA applies the science of behavior analysis to improve socially significant adaptive skills and to reduce maladaptive behaviors that threaten safety, health, or participation in daily life. ABA services are intended as ongoing, individualized supports across the lifespan to maximize functioning; they may include assessment, family training, targeted and comprehensive treatment, and coordination with other services (including educational supports) to prevent deterioration and promote independence.
Key Definitions
Level of Care: Outpatient, Focused and Comprehensive ABA
Outpatient/ABA Stage 3
Outpatient/ABA Stage 3 level-of-care criteria:
Admission rules for Stage 3
Continued authorization requirements
Discharge rules and timelines
Focused ABA, Comprehensive ABA, Stage 2 assessment
Level‑of‑care considerations for Focused ABA, Comprehensive ABA, and Stage 2 assessment:
Focused ABA admission and typical intensity
Continued stay and PA triggers for Comprehensive ABA
Discharge criteria
ABA Eligibility and Clinical Treatment Criteria
At-Risk ABA Eligibility
At‑Risk criteria for time‑limited ABA services (age 12–36 months):
At‑Risk for ASD Criteria
Diagnosed ASD ABA Eligibility
Diagnosed ASD criteria:
Diagnosed ASD Criteria
ABA clinical practice and treatment plan criteria
Stage 2 and Stage 3 clinical expectations and treatment plan elements:
Stage 2 clinical expectations
Treatment plan required elements
Treatment Modalities and Telemedicine
Focused and Comprehensive ABA
Focused and Comprehensive ABA modality description:
Treatment modality definitions
Telemedicine for ABA
Telemedicine eligibility and limits for ABA:
Telemedicine policy and licensing considerations
Visit Limits and Unit Ranges
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