Applied Behavior Analysis (ABA)
This policy governs when Applied Behavior Analysis (ABA) services for individuals with Autism Spectrum Disorder are considered medically necessary, which providers and settings are covered, and applicable coding and benefit application rules for Premera Bluecross members.
No material clinical or coverage changes in this revision.
Coverage Criteria for ABA Services
Initial and ongoing medical necessity
Covered when ALL of the following are met:
See supervision and provider rules for details.
Settings and excluded venues
Documentation must demonstrate that school-based services are bona-fide ABA rather than educational or aide functions.
Duplication and concurrent treatment
Provision of ABA concurrently with a different treatment modality (e.g., speech or occupational therapy) at the same time is considered not medically necessary.
Benefit Application - Covered and Non-covered ABA services
Covered when ABA services meet clinical criteria and are delivered as bona-fide ABA activities rather than educational or recreational services.
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Applied Behavior Analysis (ABA) services are covered only when provided for a diagnosis of Autism Spectrum Disorder as defined in the policy (DSM-5/DSM-5-TR or equivalent ICD-10 autism diagnoses). ABA is not medically necessary for diagnoses other than Autism Spectrum Disorder. Schools, tuition for specialized schools, camps, camp programs, and recreational programs are generally non-covered activities because those settings and services are primarily educational or recreational and fall outside the covered facility types, except when a specific health plan stipulation directs otherwise. Direct ABA provided in a school setting is allowed only if it consists entirely of bona-fide ABA treatment activities delivered by covered ABA providers.
Services that are routine functions or responsibilities of the school (for example, acting as a classroom aide, functioning as a 1:1 teacher, or providing services that are part of an IEP and therefore the responsibility of school personnel) are not considered ABA services and are not covered under the ABA benefit. Time spent on non-clinical activities such as preparation work distinct from analysis, or activities that substitute for school staff responsibilities, should not be billed as ABA services.
Camps, camp programs, school break or summer camps, and recreational programs (even those specific to individuals with Autism Spectrum Disorder) are non-covered because these programs are primarily recreational or educational rather than treatment-focused. Although such programs may claim to include ABA, the policy clarifies that significant portions of these programs are not bona-fide ABA treatment activities and therefore are excluded from coverage unless a specific health plan provision states otherwise.
Providing ABA concurrently with a different 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. The policy rationale is that an individual with Autism Spectrum Disorder cannot adequately focus on and engage in two different treatment modalities simultaneously; documentation must support any claimed clinical necessity for exceptions.
More than one program manager/lead behavioral therapist or more than one clinician providing direct ABA treatment to the same identified individual at the same time is considered unnecessary duplication and is not medically necessary. Exception: a second provider or provider group may be approved only when providing a short-term, highly specialized ABA-based service that the primary provider cannot deliver (e.g., a time-limited intensive feeding program); such exceptions must be documented and justified.
Specific ABA Rules and Requirements
ABA coverage criteria
Refer to Behavior Analyst Certification Board for recommendations on intensity and supervision frequency.
Behavioral Health ABA-specific rules
Rules governing ABA delivery, settings, duplication, excluded activities, and telehealth
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Permitted Levels of Care
Outpatient/Community/Home/School (limited)
Refer to Coding section for billed services and to supervision guidance for technician oversight.
Telehealth and Delivery Modalities
Telehealth / In-person / Hybrid
Services may be delivered in-person, via secure real-time telehealth, or a hybrid combination.
Refer to supervision and 2022 update evidence for telehealth effectiveness.
Telehealth / Virtual ABA
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Codes and Billing
| 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 |
Provider Responsibilities and Authorization
Coding and reimbursement requirement
Providers must bill using the CPT/HCPCS codes listed in the Coding section. Except when a specific health plan stipulation directs otherwise, in-network ABA providers must use those codes to be reimbursed. Services not listed in the Coding section are not considered medically necessary covered services for ABA. Assessments or supporting assessments performed by behavioral technicians/therapy assistants/paraprofessionals are non-covered when such activities fall outside their legally permitted scope of licensure.
- In-network providers must use the codes listed in the Coding section to be reimbursed
- Services not listed in the Coding section are not medically necessary covered ABA services
- Assessments by technicians/assistants are non-covered if outside their permitted scope
ABA medical necessity limited to Autism Spectrum Disorder
Applied Behavior Analysis (ABA) is considered medically necessary only for individuals with a diagnosis of Autism Spectrum Disorder (DSM-5/DSM-5-TR) or equivalent ICD-10 autism spectrum diagnoses. ABA is considered not medically necessary for diagnoses or conditions other than Autism Spectrum Disorder.
- Diagnosis must be made by a licensed professional authorized to diagnose psychiatric or neurodevelopmental disorders
- ABA is not medically necessary for other diagnoses
Services provided in schools — when covered vs not covered
Services provided in school settings are non-covered when they are educational activities or services that are the responsibility of school districts (including tuition for specialized schools), or when programs primarily provide educational or recreational activities rather than bona-fide ABA treatment. Coverage may be allowed for direct ABA services in the school setting only when the services consist entirely of bona-fide ABA treatment activities delivered by covered ABA providers and documented as such.
- School-based educational services, IEP services, and tuition for specialized schools are non-covered (unless a specific plan stipulation directs otherwise)
- Direct ABA delivered in school is covered only when it consists entirely of bona-fide ABA treatment activities by covered providers and is clearly documented as such
Non-covered settings and duplication (camps and recreational programs)
Camps, camp programs, recreational programs, and similar activities (including summer camps or school-break camps) are non-covered because they are recreational in nature and do not typically provide continuation of an individual's ongoing ABA treatment goals and interventions.
- Camp and recreational programs are excluded from coverage (except if specific plan stipulations direct otherwise)
- These programs generally do not continue pre-existing ABA goals or interventions and provide little direct treatment
Documentation to support medical necessity
Documentation must support medical necessity. Providers should document that services are bona-fide ABA activities in the setting delivered, include initial and periodic functional behavioral analysis results, individualized treatment plans, treatment plan revisions, data analysis, case reviews, and supervision notes as applicable. Program development and these administrative/clinical components are covered only when performed by program managers/lead behavioral therapists (or as otherwise directed by plan stipulations).
- Document initial and periodic functional behavioral analyses and how interventions map to targeted impairments
- Include treatment plans, revisions, data analysis, case review, and supervision documentation
- Program development and related activities are covered only for program managers/lead behavioral therapists
Avoidance of duplicate providers or simultaneous multiple clinicians
Avoid duplication of providers and simultaneous multiple clinicians for the same individual. 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 for the same individual during the same episode of treatment are considered unnecessary duplication and therefore not medically necessary, except in limited circumstances (for example, a second provider delivering a short-term, highly specialized, time-limited service that the primary provider cannot provide). Group treatment is an exception: only one clinician may bill for an individual in a group session even if multiple clinicians are present.
- More than one program manager/lead behavioral therapist for the same individual at the same time is not medically necessary (exceptions only by plan stipulation)
- Concurrent direct treatment by multiple clinicians for the same individual is not medically necessary
- Multiple provider groups for the same individual during the same episode are not medically necessary except for documented, time-limited specialized services
- For group treatment, only one clinician is covered for an identified individual's group session
Key Definitions
Visit and Service Limits
Background
Applied Behavior Analysis (ABA) uses principles of learning and motivation to increase desired behaviors and decrease undesired behaviors. ABA interventions are commonly applied to improve communication, attention, social skills, adaptive functioning, and to reduce problem behaviors in individuals with Autism Spectrum Disorder, using structured assessment (e.g., functional behavioral analysis), individualized treatment plans, data-driven interventions, and measurement of outcomes.
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