Prior authorization: submit detailed treatment plan and session details

Submit a documented treatment plan with clearly defined goals, objectives, and discharge criteria plus the frequency, duration, and location of requested ABA sessions for prior authorization review. The treatment plan and goal progress notes should be submitted at least once every 12 months (or as state mandated) and documentation should demonstrate monthly updates at minimum.

• Treatment plan must include goals, objectives, and discharge criteria.
• Include frequency, duration, and location of requested sessions.
• Provide treatment plan and goal progress notes at least every 12 months; document monthly updates at minimum.
• Clinical supervision hours requested must be documented.

Prior authorization for continued therapy: show services and measurable progress

For continued authorization, submit documentation of services received and a graphic representation documenting measurable progress that shows the member is benefiting, that symptoms are not worsening, and that withdrawal would risk decompensation.

• Documentation of services received (dates, types, units).
• Graphic representation of measurable progress toward or mastery of treatment goals.
• Evidence that treatment is not making symptoms worse and withdrawal would likely lead to decompensation or loss of progress.

Prior authorization & prescription: licensed prescriber required when supplemental to IEP

Coverage may be available only when ABA services are prescribed by a licensed physician or licensed psychologist and the services are not covered by the member's IEP; such services remain subject to usual plan requirements including authorization.

• Prescriptive order by a licensed physician or licensed psychologist required when services are supplemental to educational services.
• Services provided supplemental to education remain subject to authorization and plan terms.

Confirm product benefit before applying policy

Determine whether the member's product covers ABA services before applying this medical policy; if the product does not cover the service, the medical policy criteria do not apply.

• If a commercial product covers the service, medical policy criteria apply.
• If a Medicaid or Medicare product covers the service (and no local/national guidance exists), medical policy criteria apply; if the product excludes the service, deny per contract.

Request review after school-district denial (IEP exclusion cases)

If ABA services were denied by the school district and are not included in the child's IEP (including summer services), submit the request to the Health Plan for medical necessity review in accordance with the member's subscriber contract.

• If home-schooled, ensure a school district assessment has been completed prior to submission (out-of-state homeschooling reviewed individually).
• School-district denials will be reviewed for medical necessity per the subscriber contract.

Submit required documentation for medical necessity review

Submit required documentation for medical necessity review: completed psychological/other testing reports, copy of the member's IEP when applicable, progress notes and discharge plans from Early Intervention or Pre-School Special Education when applicable, certification/credentials of the ABA provider, and an assessment or treatment plan identifying target behaviors.

• Any documented psychological or other testing reports.
• Copy of member's IEP when applicable.
• Progress notes and discharge plan from Early Intervention or Pre-School Special Education when applicable.
• Certification and credentials of the professional providing ABA.
• Assessment or treatment plan identifying target behaviors.

Continued therapy: provide services record and graphic progress data

For continued therapy requests include documentation of services received and a graphic representation of measurable progress demonstrating benefit and informing the expectation that withdrawal would result in decompensation or recurrence.

• Graphic representation of progress across treatment-plan goals and domains (communication, social functioning, adaptive behavior, daily living skills, reduction of interfering behaviors).
• Documentation must support reasonable expectation of benefit from continuation.

Treatment plan & supervision documentation: maintain plan and monthly updates

Provide and maintain a documented treatment plan that includes goals, objectives, and discharge criteria; submit monthly updates at minimum and include requested clinical supervision hours with supporting documentation (treatment plan may be requested at any point).

• Treatment plan must state goals, objectives, and discharge criteria.
• At least monthly documentation updates are expected; formal review documentation submitted at least every 12 months.
• Include documentation of requested clinical supervision hours and supporting evidence of supervision arrangements.

Continued therapy documentation: include graphic progress and justification

Requests for continued therapy must include documentation of services received plus a graphic representation of measurable progress showing improvement in treatment-plan goals and that withdrawal would risk decompensation.

• Progress must be shown across applicable domains and justify continued services.
• Documentation should enable review of benefit vs. risk of withdrawal.

Document caregiver participation and school assessment status

Ensure parent/caregiver support and participation are documented as required components of the ABA program; parent support groups alone are not medically necessary. When applicable, complete an IEP through the school district prior to submitting coverage requests.

• Document caregiver training, involvement, and participation in treatment.
• Parent support groups should not be billed as medically necessary ABA services.
• If child is home-schooled, include school district assessment before submission; out-of-state homeschooling reviewed case-by-case.

Coding and documentation: use listed CPT codes and descriptors

Document services using the CPT codes listed in the policy for assessment and adaptive behavior treatment (e.g., 97151–97158, 0362T, 0373T) and include supporting descriptors per the policy when submitting claims and prior authorization requests.

• Use CPT 97151–97158 for behavior identification assessment and adaptive behavior treatment codes.
• Use 0362T and 0373T where the technician components and customized environment criteria apply.
• Include service descriptors and units in documentation to support medical necessity and billing.

Confirm product coverage and local guidance before submitting requests

Confirm product coverage and applicable local Medicare/Medicaid guidance before requesting authorization; ABA is not addressed by a CMS national coverage determination and services are contract dependent.

• If a product does not cover the service, medical policy criteria do not apply and coverage may be denied.
• If a Medicare/Medicaid product covers the service but local guidance exists, follow that guidance; otherwise apply medical policy criteria.

IEP-based services exclusion: do not request coverage for IEP-stipulated services

Coverage is not available for services stipulated in a member's IEP (ages 3–21) because those services are provided by the school district and considered free care; do not submit those IEP-stipulated services for Health Plan coverage.

• IEP exclusion applies to pre-school (age 3–5) and school-age (ages 5–21) members.
• Services included in an IEP should be provided by the school district and are excluded from Health Plan responsibility.

IEP services exclusion: ages 3–21 excluded from plan coverage

Coverage is not available for services stipulated in the IEP of pre-school (age 3–5) or school-age (age 5–21) members because these services are provided by the school district and are considered free care or a government program.

• Do not bill the Health Plan for services that are part of a member's IEP within ages 3–21.
• If services are denied by the school district and not in the IEP, submit for Health Plan review per subscriber contract.

Denial risk: demonstrate medical necessity and follow utilization review

Services must be necessary to develop, maintain, or restore functioning; failure to demonstrate medical necessity or to follow utilization review processes may result in denial and could be subject to external appeal rights per plan rules.

• Document necessity to develop/maintain/restore functioning in the member's record.
• Adhere to utilization review and authorization processes to avoid denials.