Applied Behavior Analysis (ABA) PRIOR APPROVAL REQUEST - FEP
Forms and instructions for submitting prior authorization requests for Applied Behavior Analysis (ABA) services for Federal Employee Plan (FEP) members; specifies required clinical information, service codes, units, and submission/fax instructions.
No material clinical or coverage changes in this revision.
Coverage, Medical Necessity, and Exclusions
Coverage and Exclusions
Submission must include clinical information and diagnosis verification; benefits are not available for ABA performed as part of an educational program or provided in or by a school/educational setting.
ALL of the following
- Clinical information is provided, including ICD diagnosis code.
- For initial requests: verification that diagnosis of an autism spectrum disorder was made by an appropriate diagnosing provider.
Exclusions (any of the following exclude coverage)
- ABA services performed as part of an educational program.
- ABA services provided in or by a school/educational setting.
ALL of the following
- Requested service codes and units/hours per week recorded on the prior authorization form as applicable.
- Location of service documented when requested.
- Form submitted by fax (handwritten faxes not accepted).
ABA Service Codes
| 0362T | Assessment, professional (listed on form) |
| 97151 | Behavior identification assessment, professional |
| 97155 | Adaptive behavior treatment by protocol modification, professional |
| 97156 | Family adaptive behavior treatment guidance, professional |
| 97158 | Group adaptive behavior treatment by protocol |
| 97153 | Adaptive behavior treatment by technician |
| 97154 | Group adaptive behavior treatment by technician |
Prior Authorization Submission Requirements and Methods
Prior authorization must include service codes, units/hours, location, and clinical verification
Submit a prior authorization request (Initial or Ongoing Treatment) that specifies the requested service code(s) (0362T, 97151, 97155, 97156, 97158, 97153, 97154), the units per week or hours per week for each code, location of service when requested, and clinical information including the ICD diagnosis code. For initial requests include verification that a diagnosis of an autism spectrum disorder was made by an appropriate diagnosing provider.
- List each CPT/CPT-like code being requested and the units per week or hours per week for that code.
- Provide the location of service where requested on the form.
- Include clinical information and the ICD diagnosis code.
- For Initial Requests, attach verification that an appropriate provider diagnosed an autism spectrum disorder.
Submit completed form by fax to 866-948-8823 (no handwritten faxes)
Fax the completed prior authorization request form to 866-948-8823. Handwritten faxes are not accepted.
- Use the fax number: 866-948-8823.
- Do not submit handwritten faxed forms.
Request Type Definitions
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