Applied Behavior Analysis (ABA) Coverage Criteria
Defines medical necessity, covered services, provider qualifications, settings, and coding for ABA services for members covered by this Premera Blue Cross policy; applies to ABA for Autism Spectrum Disorder.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity
Medical Necessity Criteria
Covered when ALL of the following are met
ABA is not medically necessary for other diagnoses.
Refer to the Coding section for mapped CPT/HCPCS codes and to BACB guidance for intensity recommendations.
Supervisory activities (program development, treatment plan revision, data analysis, case review, and supervision) are covered only when performed by program managers/lead behavioral therapists.
Activities that are the responsibility of the school system or that are educational/recreational in nature are not covered.
Coverage and Not Medically Necessary Criteria
Covered when services are bona-fide ABA interventions delivered by covered ABA providers and meet medical necessity criteria; the policy specifies activities considered not medically necessary or non-covered.
This exclusion does not apply to bona-fide group treatment or family therapy sessions.
Settings and Modalities
Modalities and settings
Telehealth may require increased parent/caregiver teaching and coaching during sessions.
Significant portions of school or camp programs are typically educational or recreational and therefore excluded unless otherwise directed by specific health plan stipulations.
Assessments and related activities performed by behavioral technicians, therapy assistants, paraprofessionals, or Board-Certified assistant behavior analysts that are outside their legally permitted scope of licensure are not covered (excluded). Documentation should demonstrate that any assessment billed corresponds to the provider type and scope permitted by state law and the policy coding section.
Direct ABA services delivered in school settings are covered only when they consist entirely of bona-fide ABA direct treatment activities provided by covered ABA providers. Services in schools that function as classroom aides, 1:1 teachers, or that otherwise constitute duties and responsibilities of the school district are not ABA services and are not medically necessary under this benefit.
Program development, treatment plan development/revision, data analysis, case review, and supervision are covered only when performed by a program manager/lead behavioral therapist; these administrative/supervisory functions are not separately covered when performed by technicians or assistants outside their permitted scope.
School programs and specialized school tuition for individuals with Autism Spectrum Disorder are non-covered because schools and educational programs are not covered facility types; services that are the responsibility of school districts should be provided by school staff unless a specific plan stipulation indicates otherwise.
Camps, camp programs, summer camps, and similar recreational programs are non-covered activities even if targeted to individuals with Autism Spectrum Disorder, because these programs are primarily recreational rather than ongoing, individualized ABA treatment.
Non-treatment items and activities are not covered, including provider travel time, transporting parents or other family members, babysitting, respite, and other services listed in the policy that are not behavioral assessment or treatment components.
Applied Behavior Analysis is considered medically necessary only for a diagnosis of Autism Spectrum Disorder (DSM-5/DSM-5-TR or equivalent ICD-10 diagnoses). ABA for diagnoses or conditions other than Autism Spectrum Disorder is not medically necessary.
The provision of ABA concurrently with a different type of treatment modality (for example, ABA and speech therapy or ABA and occupational therapy delivered to the same individual at the same time) is considered not medically necessary because the individual cannot adequately focus on and engage in two different treatment modalities simultaneously.
More than one program manager/lead behavioral therapist providing ABA for the same identified individual at the same time or during the same episode of treatment is considered unnecessary duplication and not medically necessary, except when a second provider group is providing a short-term, highly specialized service that is substantially different from the primary provider's services and not typically available from the primary provider.
More than one clinician providing direct ABA treatment to the same individual at the same time, or multiple agencies providing overlapping ABA services for the same episode of care, is not medically necessary. With the exception of bona-fide group treatment sessions or family therapy/collateral sessions focused on one identified individual, delivering direct ABA to more than one identified individual in the same session is also considered not medically necessary.
Billing Codes and Code Lists
| 0362T | Behavior identification supporting assessment; each 15 minutes of technicians' time face-to-face with a patient; requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior. |
| 0373T | Adaptive behavior treatment protocol with modification, each 15 minutes of technician's time face-to-face with a patient; requiring the following components: Administration by the physician or other qualified health care professional who is on site; With the assistance of two or more technicians; For a patient who exhibits destructive behavior; Completion in an environment that is customized to the patient's behavior (0373T is reported based on a single technician's face-to-face time with the patient and not the combined time of multiple technicians ). |
| 97151 | Behavior identification assessment; administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non- face-to-face analyzing past data, scoring/interpreting the assessment; and preparing the report/treatment plan. |
| 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. |
| 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. |
| 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. |
| 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 |
| S5108 | Added in history (reference to coding additions) |
| S5109 | Added in history (reference to coding additions) |
| S5110 | Added in history (reference to coding additions) |
| S5111 | Added in history (reference to coding additions) |
| 0362T | Added previously to coding (history notes) |
| 0363T | Added previously to coding (history notes) and later removed as terminated 1/1/19 |
Provider Responsibilities and Billing Requirements
Billing code requirement
Services must be billed using the specific CPT/HCPCS codes listed in the Coding section. In‑network providers of ABA must use those codes to be reimbursed; services not listed in the Coding section are not medically necessary covered services for ABA unless a specific health plan stipulation states otherwise.
- Use the codes listed in the Coding section for reimbursement.
- Services not listed in the Coding section are not covered for ABA unless the member contract or plan stipulations allow.
ABA diagnosis limitation — Not medically necessary for other diagnoses
Applied Behavior Analysis (ABA) is considered not medically necessary for diagnoses other than Autism Spectrum Disorder. ABA is covered only when the diagnosis meets the policy’s Autism Spectrum Disorder criteria (DSM/DSM‑5‑TR or equivalent ICD‑10 diagnoses) and is made by a qualified clinician within their licensure scope.
- ABA is not medically necessary for conditions other than Autism Spectrum Disorder.
- Diagnosis must be by a clinician legally permitted to diagnose psychiatric or neurodevelopmental disorders.
Multiple providers restriction — Duplication of services
Simultaneous services by more than one program manager/lead behavioral therapist or more than one clinician providing direct ABA to the same individual at the same time are generally not medically necessary and may be denied. Exceptions are limited (e.g., a time‑limited, highly specialized service that the primary provider cannot provide).
- More than one program manager/lead behavioral therapist for an individual at any one time is generally not medically necessary.
- More than one clinician providing direct ABA treatment to the same individual at the same time is generally not medically necessary.
- Exception: A second provider may be allowed when providing a time‑limited, highly specialized service distinct from the primary provider (document justification).
School and camps non‑coverage — Non‑covered school activities
Services provided in school settings that are not bona‑fide ABA direct treatment activities (for example acting as a classroom aide, 1:1 teacher, or performing functions that are the responsibility of the school/district) are not ABA services and are therefore not medically necessary under the ABA benefit.
- School‑provided educational services, IEP services, or duties that are the responsibility of the school are non‑covered.
- Direct ABA services in the school may be covered only when they consist entirely of bona‑fide ABA treatment activities delivered by covered ABA providers and documented as such.
Provider billing guidance — Use listed CPT/HCPCS codes and document service correspondence
Use the listed CPT/HCPCS codes for reimbursement and ensure documentation supports that billed services correspond to the code descriptions (service type, time increment, personnel providing service). Time spent that does not meet the code description (e.g., only charting data without analysis) should not be billed as a separate ABA service.
- Bill only the CPT/HCPCS codes listed in the Coding section (e.g., 0362T, 0373T, 97151, 97153, 97154).
- Document that the service delivered matches the code definition (provider type, face‑to‑face time, technician vs clinician role, group vs individual).
- Do not bill separate ABA codes for charting or plotting graphs when no analysis is performed.
Assessment documentation — FBA reassessments and supporting records
Functional Behavioral Assessments (FBA) and reassessments should be documented in the record; reassessments are generally conducted every 6–12 months or sooner if clinically indicated. Documentation must support the frequency, scope, and clinical rationale for the assessment or reassessment.
- FBA reassessments generally every 6–12 months unless clinical changes dictate earlier reassessment.
- Documentation should include assessment findings, interpretation, treatment implications, and justification for timing of reassessment.
Service Settings and Level-of-Care Rules
Outpatient / community-based ABA
Refer to coding and provider sections for specific covered service codes and provider types.
Documentation should demonstrate progress and justify continued intensity of services; avoid duplicated services by multiple providers.
Outpatient
Initial FBA mapped to codes such as 97151 or H0031; see Coding section.
Program development, supervision, and data analysis are covered only when performed by program managers/lead behavioral therapists.
Applied Behavior Analysis Specific Clinical Rules
ABA-specific clinical criteria
ABA is covered when delivered according to the service, provider, setting, and supervision rules detailed in the policy.
In-network providers must bill using the listed codes to be reimbursed; see Coding section for exact mappings.
Supervisory and program development activities are covered only when performed by program managers/lead behavioral therapists.
Refer to state licensure and policy guidelines for permitted activities by LaBAs/BCaBAs and other assistants.
ABA-specific clinical criteria
Behavioral health-specific ABA rules and clinical notes
Refer to policy guidelines for state-specific licensure/certification requirements.
Documentation should reflect telehealth modality and any increased caregiver training performed during sessions.
Modalities of ABA Treatment
Behavioral therapy (ABA)
Providers must bill services using the codes listed in the Coding section and follow scope-of-practice rules.
Telehealth / Virtual ABA
Telehealth sessions may involve increased caregiver coaching and should be documented accordingly.
Visit Limits and Treatment Hours
Definitions and Provider Types
Background
Applied Behavior Analysis (ABA) applies behavioral principles of antecedents and consequences to increase desired behaviors and decrease undesired behaviors. ABA is commonly used for individuals with Autism Spectrum Disorder to improve communication, social skills, attention, and adaptive functioning.
Covered ABA services include initial and periodic functional behavioral analyses, individualized treatment (one-on-one or bona-fide group), parent/caregiver education, supervision by a program manager/lead behavioral therapist, program development, data-based treatment planning and revisions, and coordination with other providers. Services may be provided in-person, via secure real-time audio/video telehealth, or a combination of modalities.
Providers must meet the policy's qualification requirements (e.g., program managers/lead behavioral therapists such as BCBAs or state-licensed behavior analysts where applicable); direct treatment may be provided by supervised behavioral technicians or assistants within their legally permitted scope and under required supervision that includes direct observation.
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