Hawaii Medicaid Supplemental Clinical Criteria — Applied Behavior Analysis (ABA)
Customize your policy alerts
Sign up for Optum Policy BH803HI0 42026 alerts
Get alerted when Policy BH803HI0 42026 changes without checking for updates manually.
Monitor payer policy activity
State-specific supplemental clinical criteria governing coverage, prior authorization, delivery, and administrative requirements for ABA services for Hawaii Medicaid (EPSDT-eligible) members, including screening, diagnosis, assessment, treatment planning, and provider credentialing.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Medical necessity and coverage criteria for ABA
Covered when ALL of the following are met:
Diagnosis must be made by an approved diagnosing provider (developmental behavioral pediatrician, developmental pediatrician, neurologist, pediatrician, psychiatrist, psychologist, or other licensed practitioner with ASD expertise). No prior authorization is required for diagnostic evaluation.
Information submitted for suspected cases should document developmental delays significantly affecting communication, interaction, behaviors, interests, and activities.
Assessment and treatment goal development follow CASP practice guidelines; the rendering provider will submit the assessment and treatment plan to the plan for prior authorization before treatment begins.
BCBA is responsible for supervision per policy; supervision frequency and direct supervision expectations are specified by practice standards.
Treatment plans must list goals and associated settings/locations where services will be delivered; rendering providers may request additional hours for school-aged members when school is not in session.
Interim assessments and PA requests must be submitted at least two weeks before the end of the approved treatment period when requesting continuation; plans must process PAs timely to avoid breaks in services.
Telehealth coverage criteria
ABA telehealth services may be covered when the following conditions are met and telehealth is clinically appropriate:
Coverage will not be provided when the requested ABA services meet any of the documented non‑coverage conditions. Specifically, services are excluded when care is primarily custodial in nature, when the member is not medically stable, when services are furnished by family or household members, when the treatment is provided as LTSS, HCBS, or respite, when treatments are considered experimental or lack scientifically proven benefit, or when services are provided outside of the State.
ABA services delivered via telehealth may be covered when provided by a licensed provider using a simultaneous HIPAA‑compliant interactive audio/video modality and when telehealth is clinically appropriate for the member; however, telehealth is not appropriate if the service requires the physical presence of a caregiver to ensure the member's health or safety.
Telehealth visits must document parental or guardian consent and must record any limitations or components that could not be completed during the telehealth encounter. When reviewing a prior authorization to deliver ABA through telehealth, consider multiple suitability factors including the member’s ability to accept telehealth, ability to participate for a reasonable period (a guide of minimum ~10 minutes), capacity to communicate with minimal caregiver prompting, ability to complete tasks without in‑person reinforcement, age and severity of behaviors, available family/support, equipment and internet connectivity in a distraction‑free location, provider telehealth training/experience, and the monitoring and assessment tools included in the treatment plan.
Codes, Billing, and Authorization Intervals
Provider Requirements, Prior Authorization, and Documentation
Prior authorization required for ABA treatment
Prior authorization is required for reimbursement of services provided under the treatment plan; rendering providers shall request prior authorization in hours/week for up to 26 weeks. Plans will prior authorize ongoing services when the member demonstrates documented improvement, amelioration, or maintenance in social skills, communication, language, behavior change, or adaptive functioning.
- Request PA in hours/week for up to 26 weeks
- PA for ongoing services requires documented improvement, amelioration, or maintenance in relevant developmental areas
Telehealth prior authorization review considerations
When reviewing a prior authorization to deliver ABA via telehealth, consider the member's ability to accept and participate in telehealth, ability to communicate with minimal caregiver prompting, ability to complete tasks without in-person reinforcement, availability of equipment/connectivity in a distraction-free location, provider telehealth training/experience, and the monitoring/assessment tools in the treatment plan.
- Member ability to accept telehealth and participate for a reasonable period (guide: minimum ~10 minutes)
- Communication with provider with minimal caregiver prompting
- Ability to complete tasks without in-person reinforcement
- Availability of adequate equipment and internet connectivity in a distraction-free location
- Provider training/experience in telehealth and monitoring/assessment tools in the plan
Screening and diagnostic PA rules
No prior authorization is required for screening services, and no prior authorization is required for a diagnostic evaluation (the plan may require a PCP referral and additional psychological testing may require PA).
- PCPs must perform developmental/behavioral screening during EPSDT visits; no PA required for screening
- Diagnostic evaluation does not require PA but may require PCP referral; additional psychological testing may require PA
Required treatment plan content
Treatment plans must describe each treatment goal, identify the standardized measurement system to reassess progress (e.g., VB-MAPP or ABLLS-R), provide an anticipated timeline and treatment hours for each goal, and document that services will be delivered by a rendering provider licensed and actively enrolled in Hawaii Medicaid.
- Description of each goal and the standardized measurement system (e.g., VB-MAPP or ABLLS-R)
- Anticipated timeline and treatment hours for each goal
- Documentation that rendering provider is licensed and actively enrolled in Hawaii Medicaid
- Obtain input from PCP, diagnosing provider, caregivers, and the member as appropriate
Interim progress assessment and re-evaluation
Interim progress assessments must document progress toward each treatment goal using a standardized measurement system, include anticipated timeline and treatment hours for goal achievement, document provider licensing/enrollment, and be submitted at least every 26 weeks; submit re-evaluation and PA request at least two weeks before the end of the approved period when requesting continuation.
- Measure progress toward each goal using a standardized system (e.g., VB-MAPP or ABLLS-R)
- Document changes to the treatment plan with accompanying goal data
- Include anticipated timeline and treatment hours based on initial and subsequent evaluations
- Submit assessments at least every 26 weeks and at least two weeks before approved period end for continuation PA
Telehealth consent and visit limitations documentation
Document parental/guardian consent for telehealth visits and record any limitations or components that could not be completed during the telehealth visit.
- Record parental/guardian consent to conduct the visit via telehealth
- Document any visit components or limitations not completed during telehealth
Non-coverage triggers
Treatment will not be covered when care is primarily custodial, the member is not medically stable, services are provided by family or household members, treatment is provided as LTSS/HCBS/respite, treatments are experimental or lack scientific benefit, or services are provided outside the State.
- Care primarily custodial in nature
- Member not medically stable
- Services provided by family or household members
- Treatment provided as LTSS, HCBS, or respite
- Treatments considered experimental or lacking scientific benefit
- Services provided outside the State
Telehealth inappropriate when physical caregiver presence required
If the service requires the physical presence of a caregiver to ensure the health and safety of the member, ABA services via telehealth are not considered an appropriate method to deliver services and may be denied.
- Telehealth is inappropriate when caregiver physical presence is required to ensure health/safety
Background and Rationale
Applied Behavior Analysis (ABA) is the recognized evidence‑based treatment approach for autism spectrum disorder (ASD). For Hawaii Medicaid members under age 21, coverage of medically necessary ABA services is governed by the federal EPSDT benefit and applicable state guidance, which require that services be provided when they are necessary to correct or ameliorate developmental conditions.
When ABA is delivered via telehealth, it must be provided using synchronous, HIPAA‑compliant audio/video technology, maintain treatment quality and effectiveness equivalent to in‑person care, and include documentation of parental/guardian consent and any visit limitations. Telehealth suitability should be assessed on an individual basis considering clinical appropriateness, member capability to participate, available supports and technology, and provider telehealth competency.
Key Definitions
Setting and Intensity Criteria
ABA-Specific Clinical Criteria
ABA clinical criteria
ABA-specific assessment, treatment planning, delivery, and monitoring requirements
Assessment components include record review, interviews, direct observation and measurement, risk assessment, and may include standardized psychometric testing and other assessments; additional testing may require PA.
Input must be obtained from the PCP, diagnosing provider, caregivers, and the member as appropriate; the rendering provider will submit the assessment and treatment plan to the plan for prior authorization before treatment begins.
May be required more often based on individual clinical circumstances; submit at least two weeks before the end of the approved period when requesting continuation.
ABA telehealth rules
Assess member ability to participate, communicate, complete tasks without in-person reinforcement, availability of equipment/connectivity, and provider telehealth competency.
Service Delivery Modalities
Telehealth (ABA)
Telehealth is not appropriate if caregiver physical presence is required to ensure member health or safety; a minimum participation duration of approximately 10 minutes may be used as a guide.
Treatment Hours and Visit Limits
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.