CurrentOptumPolicy N/A

Massachusetts Standard Form for Applied Behavior Analysis (ABA) Services Prior Authorization Requests

A standardized prior authorization request form for Applied Behavior Analysis (ABA) services in Massachusetts to be completed by the Licensed Applied Behavioral Analyst (LABA); guides submission content and required documentation for evaluation, initial, continued, or amended ABA services authorizations. Affects providers requesting ABA services for members covered by Optum in Massachusetts.

Policy Summary

PayerOptum

PolicyMassachusetts Standard Form for ABA Services Prior Authorization Requests

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a completed prior authorization form with required documentation (diagnostic report for initial evaluations and detailed treatment plan) via email or fax to Optum Behavioral Health.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsauthorization max

15 minunit length

4units per hour

CPT/HCPCScodes listed

Coverage Criteria and Required Documentation

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Required submission components

Authorization requests must include the following documentation and meet program requirements:

Authorization submission requirements: Completed form by the Licensed Applied Behavioral Analyst (LABA); diagnostic report for initial evaluations; treatment plan including assessment results and summaries (direct and indirect assessments) with baseline data and operational definitions for target behaviors; proposed goals and objectives with baselines, mastery criteria, dates, and progress data; data collection procedures; supervision plan; parent/caregiver training plan; number of hours/units requested with clinical justification and planned service location; coordination/transition/discharge/crisis plans; specified CPT/HCPCS codes and units (1 unit = 15 minutes, 4 units = 1 hour).

Requests must align with provider contract and member benefits; authorization period not to exceed 6 months.

Submission of the completed Massachusetts ABA prior authorization form does not by itself guarantee that services will be authorized. The form includes an explicit statement that submission does not guarantee authorization. Requests must also align with the provider's contract and the member's covered benefits, and the requested authorization period must not exceed 6 months.

CPT / HCPCS Codes, Unit Definitions, and Authorization Period

Covered CPT Codes (form listing)CPT

97151	Behavior Identification Assessment, Administered by a Physician or Other Qualified Health Care Professional (15-Minute Unit)
97152	Behavior Identification-Supporting Assessment by a Technician (15-Minute Unit)
97153	Adaptive Behavior Treatment by Technician (15-Minute Unit)
97154	Group Adaptive Behavior Treatment Protocol Technician (15-Minute Unit)
97155	Adaptive Behavior Treatment with Protocol, Administered by a Physician or Other Qualified Health Care Professional (15-Minute Unit)
97156	Family Adaptive Behavior Treatment Guidance, Administered by a Physician or Other Qualified Health Care Professional (15-Minute Unit)
97157	Multiple-Family Group Adaptive Behavior Treatment Guidance, Administered by a Physician or Other Qualified Health Care Professional (15-Minute Unit)

Additional CPT/HCPCS or Category III codes referencedmixed

97158	Group Adaptive Behavior with Protocol, Administered by a Physician or Other Qualified Health Care Professional (15-Minute Unit)
0362T	Behavior Identification Supporting Assessment, Administered by a Physician or Other Qualified Health Professional, On Site, with the Assistance of Two or More Technicians, for a Patient Who Exhibits Destructive Behavior (15-Minute Unit)
0373T	Adaptive Behavior Treatment with Protocol Modification, Administered by a Physician or Other Qualified Health Professional, On Site, with the Assistance of Two or More Technicians, for a Patient Who Exhibits Destructive Behavior (15-Minute Unit)

Authorization period maximum

Maximum authorization periodAuthorization period not to exceed 6 months

Request frequencyProviders may request units per week or per authorization period; authorization period must still not exceed 6 months

Alignment requirementRequests must align with member benefits and provider contract

Provider Submission Requirements and Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for evaluation, initial, continued, and amended requests. Requests must specify CPT/HCPCS codes and units being requested and must align with the provider's contract and the member's covered benefits. Submission of this form does not guarantee authorization.

Applies to requests for Evaluation, Initial Services, Continued Services, and Amended Continued Services.
Requests must specify codes and units (eg, number of 15-minute units or total units per authorization period).
Requests must align with provider contract and covered member benefits.

Denial Risk

Provider Submission Caveat

Submission of this form does not guarantee authorization. Providers are responsible for ensuring requests meet contract terms and covered benefits. Failure to include required documentation may delay or result in denial of the request.

Submission does not equal approval — authorization is subject to review and plan coverage.
Providers should verify member benefits and authorization rules prior to submission.

Documentation Required

Documentation Required with Initial Evaluation and Authorization Requests

For requests for initial evaluations, providers must include a diagnostic report with the submission. For all requests that seek service authorization, include a treatment plan containing assessments, operational definitions of target behaviors, measurable goals with baselines and mastery criteria, proposed hours, supervision plan, and any recent assessments or progress reports.

Diagnostic report required with requests for initial evaluations.
Treatment plan must include: reason for referral, assessment summaries (direct and indirect), operational definitions and baselines, proposed goals/objectives (with dates and mastery criteria), data collection procedures, supervision plan, number of hours requested with clinical justification, and billing codes requested.
Include recent functional behavior assessments, cognitive testing, progress reports, and other relevant assessments.

Note

Submission Methods

Completed forms and all required documentation must be submitted to Optum Behavioral Health by one of the following methods. Inclusion of the completed form and required attachments (diagnostic report, treatment plan, assessments) is necessary for the request to be reviewed.

Email: abatrtmntplan@optum.com
Fax: 877-217-6068

Note

Provider Action Highlights and Required Details

Providers must ensure the request specifies the services received in the past three years, the codes and units requested (per week or per authorization period), planned service locations, and any other items listed on the ABA Authorization Code Request Chart and Treatment Plan checklist. Incomplete submissions may be returned or denied.

Specify past services (IEP, IFSP, other).
Complete the ABA Authorization Code Request Chart with codes and units requested (weekly or per authorization period).
Include planned service location and full treatment plan checklist items.

Background on Applied Behavior Analysis (ABA)

Applied Behavior Analysis (ABA) services for autism spectrum disorder focus on core ASD areas including communication, social deficits, and maladaptive and repetitive/restricted behaviors. Treatment plans should identify which of these core areas will be targeted and include clear, operationally defined target behaviors with baseline data and proposed goals/objectives.

The form's treatment-plan checklist requests standard ABA elements to support authorization: reason for referral, brief background and demographics, clinical interview and assessment summaries, direct and indirect assessments with baselines, operational definitions of target behaviors, treatment setting and instructional methods, behavior management procedures and data collection methods, and proposed goals with mastery criteria.

Individual goals and objectives must include the current level (baseline), specific measurable criteria, and parent/caregiver expectations and training plans; supervision and coordination/transition/discharge/crisis plans should also be provided to justify the number of hours requested.

Definitions and Unit Conversions

ASD severity and specifiers

DSM-5 severity levelsLevel 3 — Requiring very substantial support; Level 2 — Requiring substantial support; Level 1 — Requiring support

Intellectual impairment specifierWith or Without Accompanying Intellectual Impairment

Language impairment specifierWith or Without Accompanying Language Impairment

Associated conditions specifierAssociated with Another Neurodevelopmental, Mental, or Behavioral Disorder; With Catatonia; Associated with a Known Medical or Genetic Condition or Environmental Factor

Unit

Unit definition1 unit = 15 minutes of service

Hour conversion4 units = 1 hour

Use in requestsProviders to specify number of units requested per week or per authorization period

Outpatient and Community-based ABA Level of Care

Outpatient/Community-based ABA

Covered when criteria for outpatient/community-based ABA are documented and submitted with the authorization request:

Outpatient/Community-based ABA level-of-care criteria: Diagnostic report and DSM‑5 ASD severity/specifiers documented; treatment plan meeting checklist components (assessments, operational definitions, baselines, goals/objectives with mastery criteria, supervision and parent training plans); specified service hours and planned service location (home, clinic, community, etc.); clinical justification for number of hours requested and demonstration of medical necessity per member benefits and provider contract; documentation of prior services (IEP, IFSP, early intervention, or other) as applicable.

Form requests diagnostic report with initial evaluation; authorization period must not exceed 6 months.

Treatment Plan and ABA Authorization Criteria

Treatment plan checklist

Treatment plan materials must include the following components to support authorization decisions:

Treatment plan core elements: Reason for referral; brief background and demographics (name, age, diagnosis, living situation, home/school/work information, cultural considerations); clinical interview and problem behavior information including operational definitions and hypothesized function; review of recent assessments/reports (functional behavior assessment, cognitive testing, progress reports); assessment procedures and results with summaries (graphs/tables) for indirect and direct assessments; target behaviors operationally defined with baseline levels; treatment setting and instructional methods; behavior management procedures (antecedent- and consequence-based interventions); data collection procedures; proposed goals and objectives with baseline, mastery criteria, dates, progress data, plan for generalization, and supervision plan; level of risk of harm and barriers to treatment; parent/caregiver training details; number of hours requested with clinical justification and billing codes; coordination, transition, discharge, and crisis plans.

Not all checklist items are required for every request but the form lists these critical features to support clinical review.

ABA Modalities and Billing Units

ABA modalities

Service modality must be specified on the authorization request; select applicable modality:

Service modalities: Individualized technician-delivered adaptive behavior treatment (15‑minute units); adaptive behavior treatment with protocol administered by a qualified professional; group adaptive behavior treatment (with protocol) by technician or qualified professional; family or multiple-family adaptive behavior treatment guidance by a qualified professional; behavior identification assessments (qualified professional) and behavior identification supporting assessments or destructive-behavior assessments requiring two or more technicians (0362T/0373T) as applicable.

Providers should indicate appropriate CPT/HCPCS code and units (1 unit = 15 minutes).

ABA CPT/HCPCS codes (1 unit = 15 minutes)

Units to specifyProvider must specify # of units requested per week OR # of units for the authorization period (1 unit = 15 minutes)

Time reportingRequests may report hours/week (via units) or total units for authorization period

Codes referenceApplies to ABA CPT/HCPCS codes listed on form (e.g., 97151-97157, 97158, 0362T, 0373T)