Applied Behavior Analysis
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This policy governs medical necessity, authorization, and billing for Applied Behavior Analysis (ABA) services for Providence Health Plan commercial members and outlines state-specific requirements for Oregon and Washington. It affects providers requesting ABA services and plan members receiving them.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Medical necessity and authorization criteria
Covered when ALL of the following are met:
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Benefits for actual treatment and services rendered may not be denied solely because a course of treatment was interrupted or was not completed. If a service is prescribed for a mental health condition and is medically necessary, it may not be denied solely because it is part of a category of services that is excluded by contract terms. Additionally, benefits for mental health services and substance use disorder may not be limited or denied based solely on age or condition, and coverage is not limited by age, dollar, or number of visits as specified under applicable state provisions.
All unlisted codes are reviewed at the claim level for medical necessity, correct coding, and pricing. If an unlisted code is submitted for non-covered services addressed in this policy, it will be denied as not covered. For unlisted codes that may represent potentially covered services, providers are advised to obtain prior authorization to avoid post-service denial.
Categorical denials for ABA are not permitted in situations governed by applicable state law. Specifically, for Oregon members the plan may not categorically deny treatment for ABA on the basis that the treatment is investigational and may not apply a categorical exclusion that results in denial of all ABA or other medically necessary treatment. Coverage decisions must be made through individualized determinations of medical necessity in accordance with parity requirements and applicable regulations.
Procedure Codes and Coding Rules
| 0362T | Behavior Exposure identification behavioral supporting follow-up assessment (as listed) |
| 0373T | Behavior identification/destructive behavior exposure code (as listed) |
| 97151 | Behavior identification assessment administered by a qualified health care professional (15 min) |
| 97152 | Behavior identification supporting assessment by technician (15 min) |
| 97153 | Adaptive behavior treatment by protocol, technician (15 min) |
| 97154 | Adaptive behavior treatment with protocol modification, involving a physician or other qualified health care professional (15 min) |
| 97155 | Group adaptive behavior treatment by protocol, technician (15 min) |
| 97156 | Family adaptive behavior treatment guidance, qualified health care professional (15 min) |
| 97157 | Multiple-family group adaptive behavior treatment guidance (15 min) |
| 97158 | Group adaptive behavior treatment with protocol modification, qualified health care professional (15 min) |
| 97155 | Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face, each 15 minutes (group variant referenced) |
| 97156 | 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 |
| 97157 | Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face, 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 |
Authorization, Documentation, and Claims Guidance
Prior authorization required for initial ABA services
Initial ABA services require prior authorization. Providers (or parents/legal guardians via Member Services) must submit the initial request and supporting materials for review before services begin; once authorization is granted the network BCBA will schedule the initial functional behavior assessment.
- Initial request may originate from a provider prior authorization or parent/legal guardian contacting Member Services.
- Authorization requests must be submitted prior to initiation of services; BCBA schedules the initial functional behavior assessment after authorization.
Recommend prior authorization for unlisted/potentially covered services
For unlisted or potentially covered services, obtain prior authorization to avoid post-service denial; the policy recommends prior authorization when an unlisted code is submitted for a potentially covered service.
- Prior authorization is recommended when submitting unlisted codes for potentially covered services to avoid post-service denial.
- Refer to Company prior authorization lists for additional details.
Submit required post‑assessment service requests
Submit the specific components requested after the face-to-face assessment: comprehensive assessment/observation, treatment plan, supervision hours, planned ABA therapy services, social skills groups, and parent/caregiver training (with or without the patient).
- Comprehensive Assessment and Observation or Exposure Follow‑up
- Development of Treatment Plan
- Supervision hours by BCBA to BCaBA or paraprofessional
- ABA therapy (direct member care), social skills group, parent/caregiver training (with/without patient)
InterQual review and clinical escalation for denials
Requests are reviewed using InterQual® Level of Care criteria; if a denial is based on non‑medical necessity grounds (e.g., age, diagnosis, parental involvement), the case is escalated to a supervisory clinician and then to an MD for further review.
- InterQual criteria applied to determine medical necessity.
- Non‑medical necessity denials are escalated to supervisory clinician and MD review.
Required clinical documentation for authorization
Provide comprehensive clinical documentation with authorization requests: a detailed treatment plan, full assessment reports, supervision plan and hours, and documentation of parent/caregiver training and coordination.
- Treatment plan must be developed by a qualified service provider and include demographics, reason for referral, assessment results, measurable goals, service types and hours, supervision plan, parent/caregiver participation, coordination, transition/crisis plan, and exit criteria.
- Treatment updates documented weekly and submitted to the plan at least every 6 months.
- Document number of service hours and at least 1 hour of BCBA supervision per 10 hours of direct service.
Claim‑level review; recommend prior authorization for coding/price review
All unlisted codes and claim submissions are reviewed at the claim level for medical necessity, correct coding, and pricing; to reduce risk of post‑service denials, obtain prior authorization for unlisted codes that may be covered.
- All unlisted codes are reviewed for medical necessity, correct coding, and pricing at claim level.
- Prior authorization is recommended for unlisted codes for potentially covered services to avoid post‑service denial.
Apply InterQual review and follow escalation process for denials
Use InterQual® Level of Care criteria when submitting authorization requests and escalate any denials not based on medical necessity to supervisory clinicians and MD review as described in the policy.
- InterQual criteria are applied in determining medical necessity.
- Escalation pathway: supervisory clinician → MD for further evaluation if denial is non‑medical.
Unlisted codes for non‑covered services will be denied
Unlisted codes submitted for services that this policy identifies as non‑covered will be denied as not covered; do not expect coverage for non‑covered services submitted under unlisted codes.
- If an unlisted code is submitted for non‑covered services addressed in this policy it will be denied as not covered.
- Refer to non‑covered and prior authorization lists on the Company website for details.
Setting and Level-of-Care Rules
Outpatient / community-based ABA — level-of-care criteria for outpatient/community-based settings
Outpatient / community-based ABA is covered when level-of-care and documentation requirements below are met:
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Clinical and Procedure Criteria for ABA
ABA clinical criteria — evidence-based principles and individualized treatment planning
ABA must follow evidence-based principles and individualized treatment planning:
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ABA procedure code descriptions
Supported by billing/coding descriptions in the policy (see coding section).
Covered ABA Service Types
Applied Behavior Analysis services — assessments, direct therapy, supervision, family training
Covered ABA services include the following modalities when delivered consistent with the treatment plan and authorization:
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Visit and Utilization Limits
Key Definitions
Background and Rationale
Applied Behavior Analysis (ABA) is an evidence-based behavioral intervention that targets observable, measurable behaviors to teach social, communication, adaptive and functional skills using reinforcement and systematic measurement. ABA interventions commonly include comprehensive assessment, individualized treatment planning with measurable goals, direct therapy, supervision by a qualified provider (BCBA), and caregiver/parent training to support generalization of skills across settings. InterQual® criteria are applied alongside clinical documentation to determine medical necessity for ABA services.
Coding Notes and Unlisted Code Handling
Coding warning — unlisted codes for non‑covered services denied
Submissions of unlisted codes for services identified as non‑covered in this policy will be denied as not covered; confirm coverage or request prior authorization before billing.
- The code list is provided as a courtesy and inclusion/omission does not guarantee coverage or reimbursement.
- Refer to Company prior authorization and non‑covered lists for additional guidance before submitting unlisted codes.
Policy Revision History
Procedure code descriptions for ABA services (97155–97158 and HCPCS codes) are documented with service and unit details as listed in billing guidelines.
Interim update: Removed references to Carelon throughout the policy.
Annual review with no changes to policy criteria or code configuration.
Annual review with no changes to policy criteria or code configuration.
Interim update to clarify prior authorization requirement language.
Annual update: Separated policy by line of business and changed Beacon to Carelon; also changes to verbiage in criteria.
Converted to new policy template.
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