Currentpriority healthPolicy N/A

Applied Behavioral Analysis (ABA) prior authorization form

Covers the prior authorization process and required documentation for Applied Behavioral Analysis (ABA) services for Priority Health members; applies to providers seeking authorization for initial or continued ABA treatment.

Policy Summary

Payerpriority health

PolicyApplied Behavioral Analysis (ABA) prior authorization form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form with required documentation and list units/hours requested for CPT codes 97151 and 97153–97156.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

97151-97156CPT/Service codes referenced on form

>3yEvaluation recency

Initial & continuationRequest types supported on form

Coverage Criteria for ABA Services

Initial/Continued Authorization Criteria

Authorization supported when required documentation is provided and the evaluation is current.

Documentation completeness: Provider and member information completed; evaluation date, testing instrument, and evaluator credentials included; diagnosis included; treatment plan and progress notes attached; unit/hour requests for CPT codes specified; contact name and phone provided.

Evaluation recency: If initial evaluation or if prior evaluation is more than three years old, a new evaluation must be completed.>3 years

Submission of this prior authorization form does not by itself guarantee payment. Coverage for Applied Behavioral Analysis (ABA) services is subject to the member's specific benefits and any applicable plan limits. The form must be completed with all required information and supporting documentation; incomplete or missing information may delay or prevent approval.

CPT Codes and Coding Rules

Policy Summary

Payerpriority health

PolicyApplied Behavioral Analysis (ABA) prior authorization form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form with required documentation and list units/hours requested for CPT codes 97151 and 97153–97156.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Covered CPT CodesCPTCovered

97151

Behavior identification assessment, per 15 minutes

Covered CPT CodesCPTCovered

97153

Adaptive behavior treatment by protocol, per 15 minutes (one patient)

Covered CPT CodesCPTCovered

97154

Group adaptive behavior treatment by protocol, per 15 minutes (two or more patients)

Covered CPT CodesCPTCovered

97155

Adaptive behavior treatment with protocol modification, per 15 minutes (BCBA)

Covered CPT CodesCPTCovered

97156

Family adaptive behavior treatment guidance, per 15 minutes (BCBA)

inv-08: Evaluation recency

Evaluation recency requirementIf more than three years since evaluation, a new evaluation must be completed

Where recorded on formDate of initial evaluation and testing instrument fields must be completed; form notes new evaluation required if >3 years

Effect on authorizationInitial authorization requires a current evaluation; older evaluations (>3 years) trigger requirement for new assessment before approval

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for applied behavior analysis (ABA) services. Complete the ABA authorization form for initial and continuation requests and list the units/hours requested for each CPT code.

Use the ABA authorization form for both initial and continuation requests
List units/hours requested per code (see items below)
Include authorization number for continuation requests, if available

Note

Provider Form Highlights

Provider-facing form fields include request type (initial vs continuation), treatment plan and progress notes, baseline-to-date progress, dates goals were met, dates new goals developed, discharge criteria, school status (no school / full-time / part-time), and hours/sessions of parent training completed.

Request type: Initial authorization request or Continue authorization request (include authorization number)
Treatment plan and progress notes per ABA standards
Baseline-to-date progress; dates goals met; dates new goals developed
Discharge criteria and school status
Hours/sessions of parent training completed

Documentation Required

Required Supporting Documentation

Required supporting documentation must be provided with the request. Include complete provider, member, and evaluation details to allow clinical review.

Provider/agency/practitioner name and provider tax ID
Contact name and phone
Member last name, first name, Priority Health ID#, and date of birth
Date of initial evaluation and testing instrument (if >3 years since evaluation, a new evaluation is required)
Evaluation completed by (name and credentials) and diagnosis
Number of hours that direct treatment was provided during the review period
Attach treatment plan, progress notes, and any relevant clinical documentation

Denial Risk

Incomplete Documentation May Trigger Denial

Incomplete or missing documentation may delay or result in denial of authorization. Coverage decisions are subject to the member's specific benefits.

Incomplete form fields or absent supporting documents may trigger denial or request for additional information
Coverage is subject to member-specific benefits and reviewer determination

Background

Applied Behavioral Analysis (ABA) services on this form include a behavior identification assessment (CPT 97151), technician-delivered adaptive behavior treatment by protocol (CPT 97153), group adaptive behavior treatment (CPT 97154), BCBA-delivered treatment with protocol modification (CPT 97155), and family/caregiver guidance (CPT 97156). Documentation to support authorization typically includes the initial evaluation, treatment plan, baseline-to-date progress, dates goals were met or new goals developed, hours of parent training, and number of hours of direct treatment provided during the review period. Requests may be for initial or continuation authorization and should list the specific units or hours requested per CPT code as indicated on the form.

Service Definitions (CPT Descriptions)

inv-14: 97151 — Behavior identification assessment

Code97151

Definition (per 15 minutes)Behavior identification assessment by a physician or other qualified healthcare professional, face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, plus non-face-to-face analysis, scoring/interpreting the assessment, and preparing the report/treatment plan.

Form field97151, 2 = # of hours requested

inv-15: 97153 — Adaptive behavior treatment by protocol (technician)

Code97153

Definition (per 15 minutes)Adaptive behavior treatment by protocol administered by a technician under the direction of a BCBA, face-to-face with one patient.

Form field97153, 2 = # of hours per week

inv-16: 97154 — Group adaptive behavior treatment

Code97154

Definition (per 15 minutes)Group adaptive behavior treatment by protocol administered by a technician under the direction of a BCBA, face-to-face with two or more patients.

Form field97154, 2 = # of hours per week

inv-17: 97155 — Adaptive behavior treatment with protocol modification (BCBA)

Code97155

Definition (per 15 minutes)Adaptive behavior treatment with protocol modification administered by a BCBA; may include simultaneous direction of a technician.

Form field97155, 2 = # of hours per week

inv-18: 97156 — Family adaptive behavior treatment guidance

Code97156

Definition (per 15 minutes)Family adaptive behavior treatment guidance administered by a BCBA, with or without the patient present, face-to-face with guardian(s)/caregiver(s).

Form field97156, 2 = # of hours per week

Level of Care

Outpatient/ABA — Level of Care Criteria

Outpatient/ABA level-of-care authorization criteria.

Admission/authorization: Initial authorization requires completed prior authorization form, a current evaluation (or new evaluation if >3 years), a treatment plan, and specified hours/units per CPT code (97151, 97153–97156).

Continuation authorization requires submission of the treatment plan, progress notes per ABA standards (baseline-to-date progress, dates goals met, dates new goals developed), number of hours of direct treatment provided during the review period, hours of parent training completed, and discharge criteria as applicable.

ABA Service Criteria

ABA Service Definitions

Service descriptions and administration for ABA CPT codes referenced on the authorization form.

Service types: Behavior identification assessment (97151): per 15 minutes by a physician or other qualified healthcare professional including face-to-face with patient/guardian, non‑face-to-face analysis and report/treatment plan preparation (specify # hours requested).

Service types: Adaptive behavior treatment by protocol (97153): per 15 minutes administered by a technician under BCBA direction, face-to-face with one patient (specify # hours per week).

Service types: Group adaptive behavior treatment by protocol (97154): per 15 minutes administered by a technician under BCBA direction, face-to-face with two or more patients (specify # hours per week).

Service types: Adaptive behavior treatment with protocol modification (97155): per 15 minutes administered by a BCBA, may include simultaneous direction of a technician (specify # hours per week).

Service types: Family adaptive behavior treatment guidance (97156): per 15 minutes administered by a BCBA, with or without the patient present, face-to-face with caregiver(s) (specify # hours per week).

OpenPayer

Applied Behavioral Analysis (ABA) prior authorization form

Coverage Criteria for ABA Services

CPT Codes and Coding Rules

Provider Actions and Requirements

Background

Service Definitions (CPT Descriptions)

Level of Care

ABA Service Criteria

Treatment Modalities

Visit Limits and Quantity Requests