Defines medical necessity, covered providers, settings, services, and coding for Applied Behavior Analysis (ABA) for members with Autism Spectrum Disorder; applies to providers and plan administrators.
Added CPT code 97152 for behavior identification supporting assessment administered by one technician under direction of a physician or other qualified health care professional.
Added CPT code 97157 for multiple-family group adaptive behavior treatment guidance administered by physician or other qualified health care professional without the patient present.
Modified Benefit Application statements to account for additions of CPT codes 97152 and 97157.
Telehealth/remote delivery of ABA services (including direct treatment, supervision, and ancillary services) is supported and considered non-inferior based on literature and observational experience.
Autism Spectrum Disorderrequired diagnosis for ABA coverage
Codes listedprocedure and service codes enumerated
Home/Clinic/School/Telehealthallowed service settings
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Permittedtelehealth status
Single program managerduplication rules
Coverage and Medical Necessity
Medical Necessity Criteria (Initial and Ongoing ABA)
Covered when ALL of the following are met
Diagnosis requirement: Autism Spectrum Disorder diagnosis by a clinician licensed to diagnose psychiatric or neurodevelopmental disorders (DSM-5/DSM-5-TR or equivalent ICD-10 diagnoses).
ABA is not medically necessary for other diagnoses.
Services consist of initial and periodic functional behavioral analyses; individual and group adaptive behavior treatment; caregiver/parent education, training, coaching, and support; and ABA program components such as case review, data analysis, supervision, treatment plan development and revision, and treatment team conferences.
Services must be consistent with the Coding section.
Settings and modality: Services are delivered most often in home or clinic settings but may occur in community settings, school (only bona-fide ABA direct treatment activities), or via secure real-time telehealth/virtual modalities or combinations of in-person and telehealth.
Non-ABA activities in school settings (e.g., functioning as classroom aide or providing IEP-obligated services) are not medically necessary.
Providers: Direction and supervision by a program manager or lead behavioral therapist (state-licensed or board-certified behavior analyst or other licensed clinicians as described); direct services may be provided by supervised behavioral technicians, BCaBAs as permitted, or licensed clinicians acting within their scope and supervision requirements.
Specific supervision expectations apply (see Supervision section).
General Medical Necessity Criteria for ABA
Covered when services meet ABA medical necessity criteria and are not excluded in Benefit Application
General coverage conditions: Services must be ABA assessments or interventions that utilize applied behavior analysis techniques; telehealth delivery of ABA (including direct treatment, supervision, and ancillary services) is permitted and has been demonstrated to be clinically non-inferior; only one program manager/lead therapist and one provider group should provide ABA to an individual during the same episode of treatment unless a time-limited, highly specialized secondary provider is required; provision of ABA concurrently with a different treatment modality is not medically necessary.
Exceptions for a second provider group are narrowly defined in Benefit Application.
Coverage for Applied Behavior Analysis (ABA) is limited to members with a diagnosis of Autism Spectrum Disorder as defined in the policy; ABA is not medically necessary for other diagnoses. Services provided in school settings are covered only when they consist entirely of bona-fide ABA direct treatment activities delivered by covered ABA providers; services that are educational, the responsibility of the school district, or part of an IEP are not covered. Specialized schools, school tuition, camps, recreational programs, and similar activities are non-covered because they are educational/recreational in nature rather than ABA treatment.
Assessments and supporting assessments performed by behavioral technicians/therapy assistants/paraprofessionals are non-covered unless such activities are within the legally permitted scope of their licensure. Team meetings and program activities are covered only when they are specific to treatment plan development/revision or case review for one identified individual and are billed for a single program manager/lead behavioral therapist; team meetings for broader program or group activities are not covered.
The policy lists specific activities that are not considered ABA and therefore are non-covered or not medically necessary when billed as ABA. Examples include training of behavioral technicians/assistants or BCaBAs (distinct from clinical supervision), preparation work prior to service delivery, and provider travel time.
Other non-ABA activities include accompanying the member to appointments or activities when the clinician is not actively providing treatment, transporting the member in lieu of family transport (unless treating documented significant transport-related behavioral difficulties), functioning as a school aide or tutor (except when significant behavioral difficulties are documented), babysitting, respite, live-in caregiving, general parenting coaching, training nannies/au-pairs, peer-mediated groups, and group parent training for different families.
Modalities and therapies explicitly excluded as not ABA include hippotherapy/equestrian therapy, pet therapy, auditory integration therapy, sensory integration therapy, and visual field analysis; these are considered non-ABA activities and therefore not medically necessary under the ABA benefit.
The policy generally disallows duplication of ABA providers: only one program manager/lead behavioral therapist and one provider group should provide ABA to an individual during the same episode of care. An exception allows a second provider group for a time-limited, highly specialized service not available from the primary provider.
Group treatment sessions are covered for only one clinician for billing purposes regardless of how many clinicians attend a session. With the exception of group sessions, the provision of direct ABA treatment by more than one clinician to the same individual at the same time is not medically necessary.
Assessments and programmatic services (program development, treatment plan revision, data analysis, supervision) are covered only when performed by the program manager/lead behavioral therapist; assessments performed by behavioral technicians or assistants are non-covered unless within their legally permitted scope of licensure.
Provision of ABA concurrently with a different treatment modality (for example, ABA and speech therapy or ABA and occupational therapy delivered at the same time) is considered not medically necessary. The policy notes that individuals with Autism Spectrum Disorder generally cannot adequately focus on and engage in two different treatment modalities simultaneously, which supports this restriction.
Similarly, providing ABA direct treatment services to more than one identified individual in the same session (except for bona-fide group treatment or family therapy) is not medically necessary; siblings treated together are not covered except in bona-fide family therapy or group treatment sessions.
When clinicians are present during activities outside the home (appointments, transport, recreational activities), billing as ABA is acceptable only when the clinician is actively providing ABA treatment for documented significant behavioral difficulties; otherwise these activities are considered non-ABA and are not covered.
Procedure, HCPCS and Related Codes
Covered CPT Codes (part 1)CPTCovered
0362T
Behavior identification supporting assessment, each 15 minutes of technicians' time face-to-face with a patient
0373T
Adaptive behavior treatment protocol with modification, each 15 minutes of technician's time face-to-face with a patient
97151
Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes
97152
Behavior identification supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes
97153
Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes
Covered CPT Codes (part 2)CPTCovered
97154
Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes
97155
Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes
97156
Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes
97157
Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes
97158
Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes
Covered HCPCS / H / S CodesHCPCSCovered
H0031
Mental health assessment - Used for initial evaluation/assessment, initial functional analysis, and periodic functional analysis re-assessments (must be done by a program manager/lead behavioral therapist)
H0032
Mental health service plan development - Used for program development, treatment plan development or revision, data analysis, case review, treatment team conferences, supervision of therapy assistants/paraprofessionals, and for real-time direct communication/coordination with other providers (must be done by a program manager/lead behavioral therapist)
H2014
Skills training and development, per 15 minutes - Used for direct services to member and/or parents (including parent education and training) by therapy assistants/behavioral technicians/paraprofessionals
H2019
Therapeutic behavioral services, per 15 minutes - Used for direct services to member and/or parents (including parent education and training) by program managers/lead behavioral therapists
S5108
Home care training to home care client - Used for direct services to member by therapy assistants/behavioral technicians/paraprofessionals
S5109
Home care training to home care client - Used for direct services to member by therapy assistants/behavioral technicians/paraprofessionals
S5110
Home care training, family -- Used for direct services to parents and/or family (including parent education and training) by therapy assistants/behavioral technicians/paraprofessionals
S5111
Home care training, family -- Used for direct services to parents and/or family (including parent education and training) by therapy assistants/behavioral technicians/paraprofessionals
Updated/Added CPT Codes referenced in historyCPT
97152
Behavior identification supporting assessment administered by one technician under the direction of a physician or other qualified health care professional
97157
Multiple-family group adaptive behavior treatment guidance administered by physician or other qualified health care professional without the patient present
0373T
Previously added CPT code referenced in policy history
FBA reassessment frequency
FBA reassessment frequencyFunctional Behavioral Analysis reassessments are considered medically necessary no more frequently than once every 6 months.
ApplicabilityApplies after the initial Functional Behavioral Analysis to subsequent periodic reassessments.
PurposeUsed to document ongoing treatment needs and to guide program revisions based on data and clinical progress.
Billing, Documentation, and Operational Requirements
Billing Rule
Billing code requirement / Coding updates require PA system alignment
In-network providers must bill using the CPT and HCPCS codes listed in the Coding section of this policy to be reimbursed for ABA services. Coding updates (for example additions such as CPT 97152 and 97157) require alignment with prior authorization and claims systems; verify that PA/authorization workflows and billing systems have been updated to accept newly added codes before submitting claims.
Affected codes include newly added CPT 97152 and CPT 97157 and all codes listed in the Coding section
Confirm PA system and claims adjudication accept newly added codes prior to billing
Denial Risk
Diagnosis restriction
ABA is considered medically necessary only for a diagnosis of Autism Spectrum Disorder (DSM-5/DSM-5-TR) or equivalent ICD-10 diagnoses (Autistic Disorder, Asperger's Syndrome, Pervasive Developmental Disorder Unspecified). ABA is not medically necessary for any other diagnoses or conditions.
Key Terms and Roles
Applied Behavior Analysis (ABA) definition
DefinitionA set of techniques based on learning principles that focus on antecedents and consequences to change behavior; used to improve communication, attention, social skills, and adaptive behaviors, primarily for individuals with Autism Spectrum Disorder.
Core componentsIncludes initial and periodic functional behavioral analyses, individualized and group treatment, caregiver training/coaching, data analysis, supervision, treatment planning, and team conferences.
Clinical goalIncrease desired behaviors and decrease undesired behaviors by modifying antecedents and consequences and transferring skills to caregivers.
Program manager / Lead behavioral therapist definition
DefinitionProgram manager / Lead behavioral therapist: state-licensed or board-certified behavior analysts or other licensed clinicians who direct and supervise ABA programs and perform services such as functional behavioral analyses, program development, treatment plan development/revision, data analysis, case review, treatment team conferences, and supervision of therapy assistants/technicians/paraprofessionals.
Settings and Level of Care
Outpatient / Home-based / Community-based
Allowed settings: Primary settings: home and clinic. Community settings are allowed when clinically indicated or when practicing skills where difficulties occur. Limited school-based direct treatment allowed only when behavioral difficulties related to ASD are evident and interventions are bona-fide ABA treatment activities.
Services may be delivered in-person, via secure real-time telehealth, or a combination; non-ABA school activities are not covered.
Outpatient/Community-based ABA
Outpatient/Community-based ABA specifics: Telehealth/virtual modalities for ABA (direct treatment, supervision, and ancillary services) are supported for ongoing care and may be used at any time without restriction; telehealth may emphasize earlier and increased caregiver coaching in treatment.
Revisions in history clarified telehealth allowance beyond pandemic-related restrictions.
ABA-Specific Coverage Rules
Behavioral Health ABA Criteria
ABA covered when diagnostic, service-type, setting, and provider criteria are met
Diagnosis of Autism Spectrum Disorder made by a clinician whose licensed scope includes psychiatric or neurodevelopmental diagnoses.
ABA is not medically necessary for other diagnoses.
Service types: Covered ABA services include initial and periodic functional behavioral analyses, individual and group treatment, caregiver education/training/coaching, case review, data analysis, supervision, treatment planning and revisions, and team conferences.
Services must map to the Coding section.
Settings and modality: Services may occur in home, clinic, community, school (only bona-fide ABA direct treatment), or via telehealth/virtual modalities.
Non-ABA school activities are excluded.
Therapy Types and Delivery
ABA-specific therapy
ABA therapy modalities: Covered ABA therapy modalities include behavior identification assessments, behavior identification supporting assessments, adaptive behavior treatment by protocol (individual and group), adaptive behavior treatment with protocol modification, family adaptive behavior treatment guidance, multiple-family group guidance, program development, and related supervisory and non-face-to-face components as described by CPT and HCPCS codes in the Coding section.
See Coding section for exact code descriptions and billing requirements.
Telehealth/Virtual ABA
Telehealth/Virtual ABA: Telehealth/virtual delivery of ABA services — including direct treatment, supervision, treatment planning, and ancillary services — is supported and considered non-inferior to in-person care; telehealth may involve greater caregiver coaching earlier in treatment.
Telehealth may be provided via secure real-time audio and video and in combination with in-person services.
Service Intensity and Hour Limits
Visit and intensity guidance
Visit/hour limitsNo explicit visit or hourly limits are specified in this portion of the policy; intensity recommendations are referenced to Behavior Analyst Certification Board (BACB) guidance.
DocumentationProviders should follow BACB practice guidance for intensity and document clinical rationale and data supporting chosen treatment intensity.
ScopeThis statement applies to the policy section covering visit limits and does not substitute for plan-specific benefit limits or contractual provisions.
ABA treatment hours — scope of maximum medically necessary hours
Applicability of maximum hoursThe policy clarifies that any maximum number of medically necessary daily or weekly ABA hours applies only to direct treatment hours and does not include other ABA components (e.g., assessments, program development, supervision, data analysis, team meetings).
Background and Rationale
Applied Behavior Analysis (ABA) is a set of techniques grounded in learning principles that target antecedents and consequences to increase desired behaviors and decrease undesired behaviors. ABA interventions commonly address communication, attention, social skills, and adaptive functioning in individuals with Autism Spectrum Disorder and include assessments (e.g., initial and periodic functional behavioral analyses), individualized and group treatment, caregiver education/training/coaching, and programmatic activities such as data analysis, treatment planning, and supervised delivery by trained staff.
ABA services are typically structured around measurable goals with ongoing data collection and analysis to inform treatment modifications. Care is provided under the direction and supervision of qualified program managers or lead behavioral therapists (state-licensed or board-certified behavior analysts and other appropriately licensed clinicians), with direct services delivered by supervised behavioral technicians or other permitted providers as defined by licensure and supervision requirements.
The policy recognizes telehealth/virtual delivery as an acceptable modality for ABA (including direct treatment, supervision, and ancillary services) and references literature and observational experience supporting telehealth as clinically non-inferior; intensity recommendations for treatment are referenced to professional guidance such as the Behavior Analyst Certification Board.
Documentation must show an authorized provider has diagnosed Autism Spectrum Disorder per DSM-5/DSM-5-TR or equivalent ICD-10 coding
Billing Rule
Coding and documentation
Document all ABA services using the CPT and HCPCS codes listed in the Coding section. Use the appropriate code that reflects who delivered the service and the level/type of service (e.g., technician vs program manager, individual vs group, assessment vs treatment). Assessments and supporting assessments performed by behavioral technicians/therapy assistants/paraprofessionals are non-covered unless within their legally permitted scope of licensure; those services must be billed only with codes that correspond to permitted provider types.
Use technician codes (e.g., 97152, 97153, 97154) only when performed by technicians within scope of practice
Use program manager/lead behavioral therapist codes (e.g., H0031, H0032, H2019) for assessments, plan development, supervision, and related activities as specified
Documentation Required
Documentation expectations
Document that services billed as ABA are direct ABA interventions using ABA techniques and the appropriate service descriptors. For activities billed as program management, supervision, data analysis, or treatment plan development, document the program manager/lead behavioral therapist who provided the service, the specific ABA activities performed, and how those activities relate to the member's treatment plan. For group and family guidance codes, document participant composition and whether the identified individual was present.
Clearly state the clinician role (program manager, lead behavioral therapist, technician) and licensure/certification
Document whether service was direct ABA treatment, supervision, data analysis, team meeting for a single individual, or parent/caregiver guidance
For group sessions, document whether service is billed as group treatment and which individuals were present
More than one program manager/lead behavioral therapist, more than one clinician providing direct ABA to the same individual at the same time, or more than one provider group/clinic/agency providing ABA services concurrently for the same individual is considered unnecessary duplication and generally not medically necessary. Exceptions apply only when explicitly permitted by specific health plan stipulations or when a second provider delivers a time-limited, highly specialized service substantially different from the primary provider's services.
Concurrent program managers/lead therapists for the same individual are not allowed except per plan stipulations or documented, time-limited specialized services
Multiple provider groups delivering concurrent ABA services require plan-level exception and documentation of the specialized, short-term nature of the secondary service
Denial Risk
Triggers for denial
Denial may be triggered for claims or authorizations that reflect duplication of services, unsupported provider role, unsupported diagnosis, or services not documented as ABA using ABA techniques. Common triggers include billing for assessments or supporting assessments by technicians when not permitted by scope of licensure, multiple program managers or provider groups for the same episode, billing for concurrent treatment of multiple individuals (except bona fide groups), and use of codes not listed in the Coding section.
Claims for assessments by behavioral technicians/therapy assistants when not within their licensure scope
More than one program manager/lead therapist billed for the same individual/episode without plan exception
Concurrent billing by multiple provider groups for the same individual/episode without documented exception
Services billed under codes not included in the Coding section
Note
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Covered activitiesMust perform program development, treatment plan development/revision, data analysis, case review, supervision, and real-time communication/coordination with other providers to be reimbursed as program manager activities.
Team/meeting roleTeam meetings and case review are covered only for one clinician (a program manager/lead behavioral therapist), regardless of how many clinicians attend.
Telehealth ABA definition/summary
Definition/SummaryTelehealth ABA: provision of ABA services (including direct treatment, supervision, and ancillary services such as treatment planning) via secure real-time virtual/telehealth modalities; supported as clinically non-inferior to in-person services based on literature and observational experience.
Clinical considerationsTelehealth may increase caregiver coaching earlier in treatment and can enable access for individuals in locations without in-person services.
Permitted servicesDirect treatment, supervision, program development, and other ABA components may be delivered via telehealth without time-limited restrictions.
Duplication of services definition
DefinitionDuplication of services: more than one program manager/lead behavioral therapist or more than one provider group/clinic/agency/organization providing ABA services for the same identified individual at the same time or during the same episode of treatment is considered unnecessary duplication and not medically necessary.
ExceptionsA second provider group may be medically necessary when providing a short-term, highly specialized service substantially different from the primary provider's services (e.g., intensive feeding program) that most ABA providers cannot provide.
Concurrent cliniciansMore than one clinician providing direct ABA treatment to the same individual at the same time is not medically necessary (except group treatment where rules differ).
FBA reassessment frequency:
After the initial Functional Behavioral Analysis, reassessments are medically necessary no more frequently than once every 6 months.
no more frequently than once every 6 months
As specified in policy history and thresholds.
Providers: Program managers/lead behavioral therapists (state-licensed or board-certified behavior analysts, licensed physicians, independently licensed psychologists or clinicians, or other licensed clinicians as described) must direct and supervise ABA programs; direct care may be delivered by supervised behavioral technicians, BCaBAs as permitted, and appropriately supervised masters/doctoral clinicians.
Supervision must include direct observation as clinically appropriate.
Provider and session limits
ABA-specific coverage and limits
Provider and service limits: Only one program manager/lead behavioral therapist and one provider group should provide ABA to an individual at a time; more than one program manager, more than one clinician providing direct ABA simultaneously, or more than one provider group during the same episode are considered unnecessary duplication and not medically necessary except for narrowly defined time-limited, highly specialized secondary services. For group treatment sessions, only one clinician is considered covered for an identified individual regardless of how many clinicians are present. Provision of ABA concurrently with a non-ABA treatment modality or providing direct ABA to more than one identified individual in the same session (except group or bona-fide family sessions) is not medically necessary.
Exceptions and exclusions are described in Benefit Application.
Other components excluded
Non-treatment components such as supervision, plan development, data analysis, and case review are not counted toward treatment-hour maximums.
Operational noteWhen authorizing services, distinguish treatment hours from ancillary ABA activities to correctly apply any daily/weekly hour limits.