Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.31
    OpenPayerPolicy UpdatesPsychiatry/Behavioral HealthRegence ABA Coverage Policy Update | OpenPayer
    Ask Trek AI about this page

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    CurrentRegence BlueCross BlueShieldPolicy 18

    Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder

    Customize your policy alerts

    Sign up for regence Policy 18 alerts

    Get alerted when Policy 18 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    This policy governs medical necessity, authorization, documentation, provider qualifications, and coverage criteria for ABA assessment and treatment of members with autism spectrum disorder. It applies to member contracts subject to ABA preauthorization and applicable state autism or mental health parity benefits.

    Policy Summary
    PayerRegence BlueCross Blue Shield
    PolicyApplied Behavior Analysis for the Treatment of Autism Spectrum Disorder
    Policy CodePolicy N/A
    Change TypeRoutine reviewno material change
    Effective DateNovember 1, 2026
    Last ReviewJun 1, 2026
    Next Review DateApril 1, 2027
    Key ActionVerify ABA preauthorization requirements on the applicable member-contract preauthorization website.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    3 stagesABA coverage stages addressed
    1 providerAuthorized ABA providers treating a member at one time
    Every 6 monthsObjective treatment-goal measurement during continuation
    AnnuallyStandardized treatment-goal assessment frequency
    4 statesStates with specific benefit provisions
    5 business daysContinuation documentation timing before authorization ends

    Medical Necessity and Coverage Criteria

    Initial Assessment

    An ABA-based therapy initial assessment may be considered medically necessary when all of the following criteria are met:

    ALL of the following

    • The member has been diagnosed with Autism Spectrum Disorder by a qualified treating health care professional as defined by state law.
    • ASD-related symptoms and behaviors impair the member's communication, social, and/or behavioral functioning such that the member is a safety risk to self or others and/or is unable to participate in age-appropriate home or community activities.
    • ABA therapy is recommended or prescribed by a qualified treating health care professional experienced in the diagnosis and treatment of autism, such as a psychiatrist, pediatrician, pediatric neurologist, developmental pediatrician, or psychologist, as defined by state law.

    Initiation of ABA Therapy

    Initiation of ABA-based therapy may be considered medically necessary when both the initial-assessment criteria and the individualized treatment-plan criteria are met.

    Policy Summary
    PayerRegence BlueCross Blue Shield
    PolicyApplied Behavior Analysis for the Treatment of Autism Spectrum Disorder
    Policy CodePolicy N/A
    Change TypeRoutine reviewno material change
    Effective DateNovember 1, 2026
    Last ReviewJun 1, 2026
    Next Review DateApril 1, 2027
    Key ActionVerify ABA preauthorization requirements on the applicable member-contract preauthorization website.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaABA Coding and Billing ReferenceAuthorization, Documentation, and Provider RequirementsApplied Behavior Analysis BackgroundPolicy DefinitionsABA Treatment Eligibility FrameworkEvidence and Intensity Requirements

    ALL of the following

    • Criteria I.A.-C. are met: the member has an ASD diagnosis from a qualified treating health care professional; ASD-related symptoms and behaviors impair communication, social, and/or behavioral functioning such that the member is a safety risk to self or others and/or cannot participate in age-appropriate home or community activities; and ABA is recommended or prescribed by a qualified treating health care professional experienced in autism diagnosis and treatment.

    • The individualized treatment plan (ITP) includes ALL of the following

      • The ITP is prepared by a treating provider who is certified to provide ABA therapy.
      • The ITP is documented in the medical record.
      • The ITP provides a detailed description of the specific behaviors targeted for therapy.

        Targeted behaviors must be ASD-related symptoms and behaviors that impair communication, social, and/or behavioral functioning such that the member is a safety risk to self or others and/or cannot participate in age-appropriate home or community activities.

      • For each targeted behavior, the ITP documents the member's current level of functioning and severity using objective measurements and at least one standardized assessment.
      • The ITP provides a detailed description of evidence-based treatments and techniques specific to each targeted behavior and explains how the interventions will address the ASD-related symptoms and behaviors impairing the member's functioning.
      • The ITP describes guardian/caregiver training, participation, and progress that directly support the member's ITP goals.
      • The ITP provides clinical justification for the number of days per week and hours per day of direct ABA services for the member and guardian(s)/caregiver(s), the hours per week for each treatment modality (such as face-to-face supervision or intensive group therapy), and observation of the child in the natural setting.

        Documentation must specify the services, number of units/hours requested for the specified period, authorization date range, CPT codes, and units requested.

      • The ITP includes measurable discharge and/or transition goals.

    Continuation of ABA Therapy

    Continuation of ABA-based therapy may be considered medically necessary when functional and measurable progress in ITP goals has been demonstrated and all of the following criteria are met:

    ALL of the following

    • The member has been diagnosed with Autism Spectrum Disorder by a qualified treating health care professional, as defined by state law.
    • The member continues to meet all Criteria II.B. requirements for the individualized treatment plan.

    • Progress toward each defined goal is documented with ALL of the following

      • Skill acquisition, behavior reduction, and caregiver goals are documented using data collected during treatment sessions and/or assessments, including criterion-referenced assessments.
      • Clinically significant improvements are maintained both during treatment sessions and outside the treatment setting.
      • The same measurement tool used for baseline assessments is used to describe current progress on treatment goals.
      • Objective measurements of treatment goals occur at least every six months.
      • Standardized assessments of treatment goals occur annually.
    • Documentation shows that the current targeted behaviors and ASD-related symptoms require the recommended intensity of ABA therapy and cannot be managed at a less intensive level of care.

    Initial Assessment and Initiation Documentation

    Documentation supporting initial assessment and initiation must be submitted as applicable.

    Required documentation

    • Documentation from the prescribing qualified treating health care professional of the ASD diagnosis.
    • Documentation that ASD impairs the member's functioning such that the member is a safety risk and/or unable to participate in age-appropriate activities.
    • A written recommendation, clinical order, or prescription for ABA services from the qualified treating health care professional.
    • An individualized treatment plan supporting Criteria II.B.1.-8., including requested treatment intensity and clinical justification based on individualized member needs, such as severity and frequency of problem behaviors, assessment scores compared with age-matched peers, the degree and impact of skill deficits across developmental domains, caregiver-training needs, and other relevant clinical factors.
    • Clinical justification for intensive group adaptive behavior treatment explaining why a group format is necessary to address identified deficits and why the requested frequency and duration are medically necessary.
    • Clinical justification for excessive hours, including hours above recommended standards, of supervision, assessment, social-skills, or parent-training sessions.
    • Discharge goals specifying the functional skills or developmental milestones that indicate the member has progressed sufficiently to no longer require the current intensity of services.

      Goals must reflect individualized, meaningful progress rather than timelines or generalized benchmarks and must define successful transition or reduction in services.

    • The member's most recent date of service with any previous ABA provider, if applicable.
    • The reason for discharge from the prior provider, if applicable.
    • The specific services, including modality, number of units/hours requested per specified period, authorization date range, CPT codes, and units requested.

    Continuation Therapy Documentation

    For continuation, submit the following documentation within five business days before the end of the current authorization and no more than 30 days before the end of the authorization period.

    Required documentation

    • An updated ITP containing the information required by Criteria III.A.-D.
    • When treatment goals are not demonstrating progress, a clinical rationale explaining the lack of progress, including a brief analysis of potential barriers to progress and a specific plan to modify or intensify treatment to support progress moving forward.

      This information must be clearly documented in the treatment plan and submitted with all progress reports and authorization requests.

    DSM-5 Autism Spectrum Disorder Diagnostic Criteria

    Autism spectrum disorder is defined by all of the following DSM-5 criteria, currently or by history where specified:

    ALL of Criteria A-E

    • A. Persistent deficits in social communication and social interaction across multiple contexts, manifested by ALL of the following

      • Deficits in social-emotional reciprocity, ranging from abnormal social approach and failure of normal back-and-forth conversation to reduced sharing of interests, emotions, or affect, or failure to initiate or respond to social interactions.
      • Deficits in nonverbal communicative behaviors used for social interaction, ranging from poorly integrated verbal and nonverbal communication to abnormalities in eye contact and body language, deficits in understanding and use of gestures, or a total lack of facial expressions and nonverbal communication.
      • Deficits in developing, maintaining, and understanding relationships, ranging from difficulty adjusting behavior to suit various social contexts, difficulty sharing imaginative play or making friends, or absence of interest in peers.

    • B. Restricted, repetitive patterns of behavior, interests, or activities; at least TWO of the following

      • Stereotyped or repetitive motor movements, use of objects, or speech, such as simple motor stereotypies, lining up toys or flipping objects, echolalia, or idiosyncratic phrases.
      • Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior, such as extreme distress at small changes, difficulty with transitions, rigid thinking, greeting rituals, or needing to take the same route or eat the same food every day.
      • Highly restricted, fixated interests that are abnormal in intensity or focus, such as strong attachment to or preoccupation with unusual objects or excessively circumscribed or perseverative interests.
      • Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment, such as apparent indifference to pain or temperature, adverse responses to sounds or textures, excessive smelling or touching of objects, or visual fascination with lights or movement.
    • C. Symptoms are present in the early developmental period, although they may not become fully manifest until social demands exceed limited capacities or may be masked by learned strategies in later life.
    • D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
    • E. The disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay.

      Intellectual disability and ASD frequently co-occur; comorbid diagnoses require social communication below that expected for the general developmental level.

    Autism Spectrum Disorder Severity Specification

    Current ASD severity is based on impairment in both social communication and restricted, repetitive patterns of behavior.

    Specify severity in BOTH domains

    • Social communication severity

      • Level 3 — Requiring very substantial support: Severe deficits in verbal and nonverbal social-communication skills cause severe impairment in functioning, with very limited initiation of social interactions and minimal response to social overtures from others. Example: a person with few words of intelligible speech who rarely initiates interaction, makes unusual approaches only to meet needs, and responds only to very direct social approaches.
      • Level 2 — Requiring substantial support: Marked deficits in verbal and nonverbal social-communication skills; social impairments remain apparent even with supports; limited initiation of social interactions; and reduced or abnormal responses to social overtures. Example: a person who speaks in simple sentences, whose interaction is limited to narrow special interests, and whose nonverbal communication is markedly odd.
      • Level 1 — Requiring support: Without supports, deficits in social communication cause noticeable impairments, including difficulty initiating social interactions and clear examples of atypical or unsuccessful responses to social overtures. The person may appear to have decreased interest in social interactions. Example: a person who speaks in full sentences and communicates but whose back-and-forth conversation fails and whose attempts to make friends are odd and unsuccessful.

    • Restricted, repetitive behavior severity

      • Level 3 — Requiring very substantial support: Inflexibility of behavior, extreme difficulty coping with change, or other restricted/repetitive behaviors markedly interfere with functioning in all spheres; changing causes great distress or difficulty.
      • Level 2 — Requiring substantial support: Inflexibility of behavior, difficulty coping with change, or other restricted/repetitive behaviors occur frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts; there is distress and/or difficulty changing focus or action.
      • Level 1 — Requiring support: Inflexibility of behavior causes significant interference with functioning in one or more contexts; difficulty switching between activities and problems with organization and planning hamper independence.

    ABA-based therapy is not medically necessary when used for educational, vocational, or custodial purposes.

    Code 0373T may not be billed concurrently with 97153 or 97155. Activities typically reported under 97153 or 97155 are considered part of the 0373T service and are not separately reimbursable. Providers must bill using the appropriate CPT codes, including modifiers.

    An ABA-based therapy initial assessment is considered not medically necessary when any requirement of Criterion I is not met.

    Initial or continued ABA-based therapy for all indications is considered not medically necessary when any requirement of Criterion II is not met, including when ABA-based therapy is used for educational, vocational, or custodial purposes.

    When policy criteria are not met, the ABA initial assessment, initiation, and continuation of treatment for ASD are considered not medically necessary.

    ABA Coding and Billing Reference

    Referenced ABA CPT CodesCPT
    0362TBehavior identification supporting assessment, each 15 minutes of technicians' time, face-to-face with a patient; the notes also describe 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 in an environment customized to the patient's behavior.
    Referenced ABA CPT CodesCPT
    0373TAdaptive behavior treatment with protocol modification, each 15 minutes of technicians' time, face-to-face with a patient, requiring 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 in an environment customized to the patient's behavior.
    Referenced ABA CPT CodesCPT
    97151Behavior 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 the patient and/or guardian(s)/caregiver(s), including assessment discussion, analysis of past data, scoring/interpreting the assessment, and preparation of the report/treatment plan.
    97152Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes.
    Concurrent Billing Restriction CodesCPT
    97153Referenced in the billing restriction for services that may not be billed concurrently with 0373T.
    97155Referenced in the billing restriction for services that may not be billed concurrently with 0373T.
    Behavior identification assessment servicesCPT
    97151Behavior 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.
    97152Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes.
    Adaptive behavior treatment servicesCPT
    97153Adaptive 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.
    97154Group 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.
    ABA CPT Codes ListedCPT
    97151Behavior 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.
    97152Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes.
    97153Adaptive 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.
    97154Group 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.
    97155Adaptive behavior treatment with protocol modification, administered by.
    ABA CPT Codes IdentifiedCPT
    97151Behavior 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.
    97152Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes.
    97153Adaptive 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.
    97154Group 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.
    97155Adaptive behavior treatment with protocol modification, administered by.
    ABA CPT CodesCPT
    97151Behavior 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.
    97152Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes.
    97153Adaptive 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.
    97154Group 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.
    97155Adaptive behavior treatment with protocol modification, administered by.
    ABA procedure codes referenced in NotesCPT
    97151Behavior identification assessment, administered by a physician or other qualified health care professional's time face-to-face with patient and/or recommendations, and non-face-to-face analyzing past data.
    97152Face-to-face with the patient, each 15 minutes.
    97153With one patient, each 15 minutes.
    97154Face-to-face with two or more patients, each 15 minutes.
    97155Code referenced in the Notes section; description is not discernible in the available source text.
    DSM-5 Autism Spectrum Disorder diagnosismixed
    299.00Autism Spectrum Disorder.
    F84.0Autism Spectrum Disorder.
    Service unit duration
    Unit basisEach service unit represents 15 minutes.
    Assessment servicesBehavior identification assessment and behavior identification-supporting assessment are described in 15-minute units.
    Treatment servicesAdaptive behavior treatment by protocol is described in 15-minute units for individual treatment; group treatment is also reported in 15-minute units.
    Restricted/repetitive behavior manifestations
    Required thresholdAt least 2 of 4 manifestations must be present.
    Manifestation 1Stereotyped or repetitive motor movements, use of objects, or speech.
    Manifestation 2Insistence on sameness, inflexible adherence to routines, or ritualized patterns.
    Manifestation 3Highly restricted, fixated interests abnormal in intensity or focus.
    Manifestation 4Hyper- or hyporeactivity to sensory input or unusual sensory interests.

    Authorization, Documentation, and Provider Requirements

    Prior Authorization

    Verify Contract Preauthorization

    Before requesting ABA services, verify whether the member’s group contract requires preauthorization. Requirements vary by contract, so confirm them on the applicable preauthorization website.

    • Applies only to contracts subject to ABA preauthorization.
    • Check the member contract and preauthorization requirements before submission.
    Documentation Required

    Submit Supporting Clinical Records

    Submit clinical documentation supporting the applicable medical-necessity criteria with the authorization request.

    • Include required diagnostic, functional-impairment, recommendation, treatment-plan, progress, and service documentation.
    • See the Required Documentation requirements for the applicable request.
    Prior Authorization

    Authorization Required for Initiation and Continuation

    Authorization documentation is required for both initiation and continuation of ABA-based therapy. Initiation requires the qualified treating professional’s recommendation, diagnosis and functional-impairment documentation, and an individualized treatment plan with required service details; continuation requires updated progress and treatment-plan documentation.

    • Initiation: written recommendation, clinical order, or prescription for ABA services.
    • Initiation: diagnosis of ASD and documentation of safety risk or inability to participate in age-appropriate activities.
    • Continuation: document functional and measurable progress and continued need for the recommended intensity.
    Documentation Required

    Prescriber Documentation

    Obtain and submit documentation from the prescribing qualified treating healthcare professional supporting the ASD diagnosis, functional impairment, and recommendation for ABA.

    • Document that ASD impairs communication, social, and/or behavioral functioning.
    • Document that the member is a safety risk and/or cannot participate in age-appropriate home or community activities.
    • Include the provider’s written recommendation, clinical order, or prescription.
    Documentation Required

    Individualized Treatment Plan

    Prepare an individualized treatment plan (ITP) in the medical record that identifies the targeted ASD-related behaviors, establishes objective baseline severity, and defines measurable treatment and discharge or transition goals.

    • The ITP must be prepared by a treating provider certified to provide ABA therapy.
    • Describe each targeted behavior and how it impairs functioning.
    • Use objective measurements and at least one standardized assessment to document current functioning and severity.
    • Describe evidence-based interventions specific to each targeted behavior.
    • Document caregiver training, participation, and progress supporting ITP goals.
    • Include measurable discharge and/or transition goals.
    Documentation Required

    Requested Services and Intensity

    Support the requested service intensity with individualized clinical rationale. The request must explain the number of days and hours, each treatment modality, and why the requested services are medically necessary.

    • Justify intensity using factors such as severity and frequency of problem behaviors, assessment scores compared with age-matched peers, functional skill deficits, and caregiver-training needs.
    • Justify the frequency and duration of intensive group adaptive behavior treatment and why group treatment is necessary.
    • Explain why the recommended intensity cannot be managed at a less intensive level of care.
    • Dosage must not be based solely on diagnosis, caregiver availability, or scheduling preferences.
    Documentation Required

    Continuation Progress Documentation

    For continuation requests, submit measurable progress documentation covering skill acquisition, behavior reduction, caregiver goals, maintenance, and the member’s current need for treatment intensity.

    • Use treatment-session and/or assessment data, including criterion-referenced assessments.
    • Document clinically significant improvement both during treatment and outside the treatment setting.
    • Use the same measurement tool as the baseline assessment.
    • Measure treatment goals objectively at least every six months and use standardized assessments annually.
    • Document that current targeted behaviors require the recommended intensity and cannot be managed at a less intensive level of care.
    Documentation Required

    Prescribing Professional Records

    Include required documentation from the prescribing qualified treating healthcare professional in the initiation submission.

    • ASD diagnosis.
    • Documentation of functional impairment, safety risk, or inability to participate in age-appropriate activities.
    • Written recommendation, clinical order, or prescription for ABA services.
    Documentation Required

    ITP Criteria and Clinical Justification

    Ensure the ITP supports the treatment criteria, requested intensity, and clinical justification for each service and modality.

    • Document targeted behaviors, objective baseline and severity measures, evidence-based interventions, caregiver participation, and discharge or transition goals.
    • Provide individualized justification for the requested hours and frequency.
    • Explain the medical necessity of group treatment and any excessive supervision, assessment, social-skills, or parent-training hours.
    Documentation Required

    Prior ABA Provider History

    When applicable, document the member’s most recent date of service with any previous ABA provider and the reason for discharge.

    • Include prior ABA provider history in the initiation request.
    • The member may receive ABA treatment from only one authorized ABA provider at a time.
    Documentation Required

    Requested Service Details

    Specify exactly what services are requested so the authorization can be matched to the treatment plan and billing submission.

    • Include each service modality.
    • List units or hours requested for the specified period.
    • Provide the authorization date range, CPT codes, and units requested.

    Unsupported block type: prior_auth

    Documentation Required

    Lack of Progress Documentation

    When treatment goals are not demonstrating progress, explain the lack of progress and document a corrective treatment plan.

    • Provide a brief analysis of potential barriers to progress.
    • Describe a specific plan to modify or intensify treatment to support progress.
    • Document this information clearly in the treatment plan and submit it with progress reports and authorization requests.
    Denial Risk

    Failure to Meet Medical Necessity Criteria

    An initial ABA assessment is not medically necessary when the diagnostic, functional-impairment, or qualified-professional recommendation criteria are not met. Initial or continued ABA therapy is also not medically necessary when the initiation treatment-plan criteria are not met, including use for educational, vocational, or custodial purposes.

    • Failure to meet Criterion I results in denial of the initial assessment.
    • Failure to meet Criterion II results in denial of initial or continued ABA-based therapy.
    Denial Risk

    Insufficient Progress or Excessive Intensity

    Continuation may be denied when the member does not demonstrate functional and measurable progress toward ITP goals or when the requested intensity is not supported.

    • Document skill acquisition, behavior reduction, caregiver goals, maintenance, and objective progress.
    • Show that the same baseline measurement tool supports current progress.
    • Explain why the current targeted behaviors require the recommended intensity and cannot be managed at a lower level of care.
    Denial Risk

    One Authorized ABA Provider at a Time

    The member is limited to ABA treatment from one authorized ABA provider at any given time.

    • Verify whether another ABA provider is currently authorized before initiating services.
    • Document the prior provider’s most recent service date and discharge reason when applicable.
    Denial Risk

    Unsupported Treatment Intensity

    Requested treatment intensity must be supported by individualized clinical documentation, including justification for group treatment and any supervision or related hours.

    • Explain recommended ABA hours using severity, frequency of behaviors, assessment results, functional deficits, caregiver-training needs, and other relevant clinical factors.
    • Justify why intensive group treatment is necessary, including its requested frequency and duration.
    • Justify excessive supervision, assessment, social-skills, or parent-training hours.
    Denial Risk

    Policy Criteria Not Met

    If any applicable policy criterion is not met, the initial assessment, initiation, or continuation of ABA treatment for ASD is considered not medically necessary.

    • Review all diagnostic, functional, recommendation, treatment-plan, progress, intensity, and service-detail requirements before submission.
    • Address deficiencies before requesting authorization.
    Denial Risk

    Insufficient Intensity Justification

    The requested intensity must be clinically individualized rather than based solely on diagnosis, caregiver availability, or scheduling preferences.

    • Relate hours and frequency to the member’s symptoms, functional needs, behavior severity, assessment findings, skill deficits, and caregiver-training needs.
    • Explain why the requested level is necessary and why a less intensive level of care is insufficient.
    Denial Risk

    Unsupported Intensive or Excessive Services

    Intensive group treatment and excessive service hours require specific clinical justification in the ITP and authorization request.

    • Explain why group treatment is necessary to address the member’s identified deficits.
    • Justify the requested group-treatment frequency and duration.
    • Justify excessive hours for supervision, assessment, social skills, or parent training.
    Billing Rule

    Concurrent Billing Restriction

    Providers must bill with appropriate CPT codes and modifiers. Code 0373T may not be billed concurrently with 97153 or 97155.

    • Activities typically reported under 97153 or 97155 are considered part of the 0373T service when applicable.
    • Those activities are not separately reimbursable when included in 0373T.

    Applied Behavior Analysis Background

    Applied Behavior Analysis (ABA) is an umbrella of principles and techniques used to assess, treat, and prevent challenging behaviors and to promote desired behaviors through systematic reinforcement. For autism spectrum disorder, ABA may be used to teach skills, support generalization, and reduce behaviors that impair communication, social, or behavioral functioning.

    Policy Definitions

    Standardized assessment
    AdministrationThe assessment is administered in a consistent, predetermined manner.
    ScoringThe assessment is scored using a consistent, predetermined process.
    Normative comparisonPerformance is typically compared with a normative sample, such as same-age peers.
    ValidityThese tools are generally norm-referenced, reliable, and validated through large-scale research.
    Criterion-referenced assessment
    Assessment basisPerformance is evaluated against a defined set of skills or criteria rather than a normative sample.
    Treatment useThe assessment guides treatment planning and skill acquisition.
    StructureThese assessments are often tied to a curriculum or developmental sequence and are highly structured.
    Diagnostic roleCriterion-referenced assessments are used to guide treatment planning and skill acquisition rather than diagnosis or eligibility.
    Evidence-based treatment
    Research foundationInterventions are grounded in rigorous scientific research demonstrating effectiveness in improving meaningful outcomes for individuals on the autism spectrum.
    Supporting evidenceTreatments are supported by multiple high-quality studies conducted by independent researchers.
    Research standardsStudies use established research designs and are published in peer-reviewed journals.
    ExamplesExamples include Natural Environment Training, Discrete Trial Training, Shaping, Chaining, Differential Reinforcement, Incidental Teaching, and Pivotal Response Training.
    Qualified and supervised ABA provider
    Qualifying providersQualified ABA providers include a Lead Behavior Analysis Therapist (LBAT) and, in Idaho, a credentialed provider with BCBA certification issued by the Behavior Analyst Certification Board.
    Independent oversightBCBAs and BCBA-Ds may independently oversee assessment, treatment planning, and supervision of support staff in accordance with BACB guidelines.
    Supervised providersBCaBAs, behavior analysts in training, and RBTs must work under required supervision and may not practice independently or independently design programs or perform assessments.
    Supervision standardSupervision must follow the behavior analyst certification board's professional and ethical compliance code and current supervision standards.
    Autism Spectrum Disorder (ASD)
    ClassificationAutism Spectrum Disorder is a neurodevelopmental disorder.
    Core characteristicsASD is characterized by impaired social communication and interaction and atypical interests and behavioral patterns.
    Associated conditionsASD may be accompanied by conditions such as epilepsy and cognitive impairment.
    Applied Behavior Analysis (ABA)
    PurposeApplied Behavior Analysis is applied in the assessment, treatment, and prevention of challenging behaviors.
    Skill promotionABA promotes new desired behaviors.
    Common applicationThis method is often used for Autism Spectrum Disorder.
    Individualized Treatment Plan (ITP)
    Member-specific planAn Individualized Treatment Plan is tailored to the member and supports the applicable ABA criteria.
    Required contentThe plan documents treatment intensity, clinical justification, goals, and discharge or transition planning.
    Authorization useThe plan supports initiation or continuation requests and must justify requested intensity based on individualized member needs.
    Autism spectrum disorder
    Social communication and interactionPersistent deficits must occur across multiple contexts, including social-emotional reciprocity, nonverbal communication, and developing, maintaining, or understanding relationships.
    Restricted or repetitive behaviorsRestricted, repetitive patterns of behavior, interests, or activities must be manifested by at least 2 of 4 specified features.
    Development and impairmentSymptoms must be present in the early developmental period and cause clinically significant impairment in social, occupational, or other important areas of current functioning.
    Differential diagnosisThe disturbances must not be better explained by intellectual disability or global developmental delay.

    ABA Treatment Eligibility Framework

    ABA Treatment Criteria

    ABA assessment, initiation, and continuation are medically necessary only when the applicable diagnosis, impairment, provider, treatment-plan, progress, and intensity criteria are met.

    ABA medical necessity

    • Qualifying diagnosis and impairment: The member has ASD diagnosed by a qualified treating health care professional, and ASD-related symptoms and behaviors cause functional impairment such that the member is a safety risk and/or cannot participate in age-appropriate activities.
    • Qualified recommendation and provider: ABA is recommended or prescribed by a qualified treating professional, and the individualized treatment plan is prepared by a provider certified to provide ABA therapy.
    • Individualized treatment plan: The documented treatment plan is individualized, evidence-based, measurable, includes objective baseline and severity measurements with at least one standardized assessment, caregiver participation, treatment intensity and modality justification, natural-setting observation, and discharge or transition goals.
    • Continuation progress and intensity: For continuation, measurable progress is documented for skill acquisition, behavior reduction, and caregiver goals; improvement is maintained and generalized; measurements occur at least every six months with annual standardized assessments; and the requested intensity is necessary over a less intensive level of care.

    ABA Initiation and Continuation

    ABA for ASD may be medically necessary when applicable policy criteria are met and the required initiation or continuation documentation is submitted.

    ABA initiation and continuation documentation

    • Initiation: For initiation, submit ASD diagnosis and functional-impairment documentation from the prescribing qualified treating professional, a written recommendation, clinical order, or prescription, an individualized treatment plan with individualized intensity justification and discharge goals, prior ABA provider information when applicable, and requested services, units, dates, and CPT codes.
    • Continuation: For continuation, submit an updated individualized treatment plan and supporting progress documentation before the current authorization ends.Within 5 business days before authorization end and no more than 30 days before authorization end

      If goals are not progressing, explain barriers and provide a specific plan to modify or intensify treatment.

    DSM-5 Diagnostic Basis for ABA Treatment

    The documented diagnostic basis for ABA treatment is autism spectrum disorder meeting DSM-5 criteria.

    Documented DSM-5 autism spectrum disorder diagnosis: The individual meets DSM-5 criteria A through E for autism spectrum disorder, including persistent social communication and social interaction deficits, at least two restricted or repetitive behavior manifestations, early developmental onset, clinically significant functional impairment, and exclusion of a better explanation by intellectual disability or global developmental delay.At least 2 of 4 criterion B manifestations

    The diagnosis must be documented by a qualified treating health care professional as required by the applicable treatment criteria.

    Evidence and Intensity Requirements

    Evidence-Based ABA Treatment

    ABA treatment must use evidence-based interventions.

    Evidence-based ABA techniques: Use interventions grounded in rigorous scientific research, supported by multiple high-quality studies from independent researchers using established research designs and published in peer-reviewed journals.

    Examples include Natural Environment Training, Discrete Trial Training, Shaping, Chaining, Differential Reinforcement, Incidental Teaching, Pivotal Response Training, Direct Instruction, Referent-Based Instruction, Skills Based Training, and Relational Frame Theory. The list is illustrative and not exhaustive.

    Intensive Group Adaptive Behavior Treatment

    Intensive group adaptive behavior treatment requires individualized clinical justification.

    Intensive group adaptive behavior treatment: When intensive group adaptive behavior treatment is requested, provide clinical justification explaining why a group treatment format is necessary to address the member's identified deficits and why the requested frequency and duration are medically necessary.