CurrentPremera BluecrossPolicy N/A

Applied Behavior Analysis (ABA) PRIOR APPROVAL REQUEST-FEP

Template/prior approval request form for ABA services (assessments, program modification, family/group/direct technician services) for FEP members; used by providers/agents to request initial or ongoing treatment authorization.

Policy Summary

PayerPremera Bluecross

PolicyApplied Behavior Analysis (ABA) PRIOR APPROVAL REQUEST-FEP

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior approval request form with required verification of ASD diagnosis for initial requests and include Tax ID and NPI when faxing to FEP fax 866-948-8823.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiplecodes referenced on form

Home/Clinic/Schoollocations of service fields present

866-948-8823submission fax number

877-342-5258contact for misdirected communication

Coverage Criteria

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Exclusion note regarding educational settings

Benefits are not available for ABA performed as part of an educational program or when services are provided in or by a school or educational setting.

For coverage determination, ABA services provided in school settings are excluded. See the member's Blue Cross & Blue Shield Service Benefit Plan, Section 6 General Exclusions, or visit fepblue.org/plan-brochures for plan-specific details.

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Required clinical verification for initial requests

Initial requests must include clinical information and an ICD diagnosis code.

Include verification that a diagnosis of an autism spectrum disorder was made by an appropriate diagnosing provider.

Policy Summary

PayerPremera Bluecross

PolicyApplied Behavior Analysis (ABA) PRIOR APPROVAL REQUEST-FEP

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior approval request form with required verification of ASD diagnosis for initial requests and include Tax ID and NPI when faxing to FEP fax 866-948-8823.

SourceLink

On This Page

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Provider Actions & Submission

Prior Authorization

Prior Authorization Required

Prior authorization is required for initial and ongoing Applied Behavior Analysis (ABA) treatment. Submit a completed ABA Prior Approval Request form that includes: member and provider identifiers, ICD diagnosis code, verification that an autism spectrum disorder diagnosis was made by an appropriate diagnosing provider for initial requests, and the requested CPT/HCPCS services with units or hours per week and location of service for each requested code.

Include requested codes and specify units/hours per week for each service (e.g., 0362T, 97151, 97155, 97153, 97154).
For initial requests, include documentation verifying the ASD diagnosis by an appropriate diagnosing provider.
Do not request ABA services delivered as part of an educational program or provided in/by a school setting (these are excluded).

Note

Submission Instructions and Contact

Submit the completed ABA Prior Approval Request form and supporting documentation by fax to the FEP prior authorization fax line. Handwritten faxes are not accepted. Include required provider identifiers on the form and fax: Tax ID and NPI. Ensure the form lists the member’s date of birth, group number, contact person and phone, and the requested service details including location (Home, Clinic, School where applicable).

FEP fax to: 866-948-8823
Handwritten faxes not accepted
Required provider identifiers: Tax ID and NPI must be provided on the request form
Include member identifiers: Member ID, date of birth, group #, and suffix where applicable

Definitions & Form Fields

Initial Request

TermInitial Request

DefinitionAn Initial Request is a prior approval submission for ABA services that must include verification that the diagnosis of an autism spectrum disorder was made by an appropriate diagnosing provider.

Required documentationClinical information and ICD diagnosis code must be provided on the form for initial requests.

Service quantity and location fields — Units per week / Hours per week and Location of Service fields

Units per week / Hours per weekThe form provides fields to specify units per week and hours per week for each listed service code (e.g., 0362T, 97151, 97155, 97156, 97158, 97153, 97154).

Location of Service optionsLocation fields enumerate Home, Clinic, and School (noting that school is marked with asterisk and subject to exclusions).

Per-location breakdownThe form includes fields to specify units per week at each location of service when applicable.

OpenPayer

Applied Behavior Analysis (ABA) PRIOR APPROVAL REQUEST-FEP

Coverage Criteria

Service Codes Referenced

Provider Actions & Submission

Definitions & Form Fields

0362T	Assessment; professional (CPT-like)
97151	Behavior identification assessment, administered by a physician or other qualified health care professional
97155	Adaptive behavior treatment modification
97156	Family adaptive behavior treatment guidance
97158	Group adaptive behavior treatment by professional
97153	Adaptive behavior treatment by technician (direct)
97154	Adaptive behavior treatment by technician in group