CurrentWellpointPolicy N/A

Developmental Individual-Difference Relationship-Based (DIR) UM Guideline

Customize your policy alerts

Sign up for all wellpoint policy alerts

Know when wellpoint releases new policies or updates existing guidance.

Monitor payer policy activity

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

This guideline governs medical necessity, prior authorization, treatment planning, continued-stay review, provider qualifications, and billing guidance for DIR developmental services for individuals with autism spectrum disorder under New Jersey Medicaid.

Policy Summary

PayerWellpoint

PolicyDevelopmental Individual-Difference Relationship-Based (DIR) UM Guideline

Policy CodePolicy N/A

Change TypeNon-material revision

Effective DateJul 1, 2020

Last ReviewOct 7, 2021

Next Review DateN/A

Key ActionSubmit an updated treatment plan generally every 6 months for continued DIR treatment.

SourceLink

POLICY UPDATE CHANGES

The policy was revised on 5/15/2024 based on State guidance dated 5/17/2023.

ASDCovered population

6 months

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.

CurrentWellpointPolicy N/A

Developmental Individual-Difference Relationship-Based (DIR) UM Guideline

Customize your policy alerts

Sign up for all wellpoint policy alerts

Know when wellpoint releases new policies or updates existing guidance.

Monitor payer policy activity

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

Policy Summary

PayerWellpoint

PolicyDevelopmental Individual-Difference Relationship-Based (DIR) UM Guideline

Policy CodePolicy N/A

Change TypeNon-material revision

Effective DateJul 1, 2020

Last ReviewOct 7, 2021

Next Review DateN/A

Key ActionSubmit an updated treatment plan generally every 6 months for continued DIR treatment.

SourceLink

POLICY UPDATE CHANGES

The policy was revised on 5/15/2024 based on State guidance dated 5/17/2023.

ASDCovered population

6 months

Treatment-plan update interval

1-2 hours/weekQHP supervision

8Group session maximum

NonePreset limitations under EPSDT

Medical Necessity and Coverage Criteria

Initial DIR assessment and planning

Assessment and planning for an initial course of DIR intervention services may be covered when all criteria are met.

Diagnosis and provider: ASD diagnosis was made by a licensed medical professional or other qualified healthcare professional consistent with state licensing requirements.
Person-centered treatment plan
- Measurable goals: Goals are objective and measurable, based on standardized assessments, and address the behaviors and impairments targeted by the intervention.
  For each goal, document baseline measurements, progress to date, and an anticipated achievement timeline based on the initial and subsequent interim assessments.
- Provider qualification: DIR services will be delivered by an appropriately licensed or certified provider under applicable state laws and benefit-plan requirements.
Functional assessments: Assessments of physical, motor, language, social, and adaptive functions have been completed.
Age- and impairment-appropriate goals: The treatment plan incorporates goals addressing deficient social, communication, language, or adaptive functioning relative to age-expected norms.
For each target, document family education and caregiver-training interventions, anticipated achievement timeline, generalization plan, estimated mastery date, and discharge or transition planning.

Continued-stay criteria

Continuation of treatment may be covered when all criteria are met.

Continued DIR treatment

Updated treatment plan: The treatment plan is updated and submitted generally every 6 months or as required by a state mandate.Every 6 months
Age- and impairment-appropriate goals and progress measures: The treatment plan includes appropriate goals and measures of progress for social skills, communication skills, language skills, adaptive functioning, and specifically targeted behaviors or deficits.
Progress assessment: Clinically significant progress is documented in social skills, communication skills, language skills, and adaptive functioning.
An interim progress assessment is required at least every 6 months, and developmental status must be measured by standardized assessments no less frequently than every 6 months.

Not medically necessary

DIR services are not medically necessary when either condition is present.

Criteria failure: The initial-course or continued-stay criteria are not met.
Insufficient progress: An interim progress evaluation using standardized assessments does not document clinically significant progress in adaptive functioning, communication skills, language skills, or social skills.
Failure to document clinically significant progress in any one of these areas is sufficient under the policy wording.

DIR services are not covered and not medically necessary when the applicable initial-course or continued-stay criteria are not met.

DIR services are not covered and not medically necessary when an interim progress evaluation using standardized assessments does not document clinically significant progress in any required area: adaptive functioning, communication skills, language skills, or social skills.

Covered Services and Billing Guidance

Assessment, treatment-plan development, and reassessmentCPTCovered

96156 EP

Initial assessment and development of a treatment plan as well as reassessment; per diem; 1 unit, up to 6 units per 6-month authorization period; licensed and DIR-certified QHP.

Treatment supervisionCPTCovered

96156 EP26

Supervision of treatment and/or treatment-plan reassessment and development by a QHP; must be face-to-face with the member and supervised individual; minimum 4 units and up to 8 units per calendar week for each supervisee; DIR QHP or provider with minimum of Master's degree.

Behavior treatment by protocolCPTCovered

96158	Behavior treatment by protocol; initial 30 minutes; 1 unit; DIR QHP, DIR Supervisor, or DIR-certified provider under the direction of a DIR QHP or Supervisor.
96159 EP	Behavior treatment by protocol; each additional 30 minutes; 30 units; DIR QHP, DIR Supervisor, or DIR-certified provider under the direction of a DIR QHP or Supervisor.

Group-led sessionsCPTCovered

96164	Group-led sessions for a maximum of 8; initial 30 minutes; 1 unit; DIR QHP, DIR Supervisor, or DIR-certified provider under the direction of a DIR QHP or Supervisor.
96165 EP	Group-led sessions for a maximum of 8 individual patients; each additional 15 minutes; 22 units; DIR QHP, DIR Supervisor, or DIR-certified provider under the direction of a DIR QHP or Supervisor.

Family guidance servicesCPTCovered

96167 EP	Guidance services to a family with an autistic child; initial 30 minutes; 1 unit; DIR QHP, DIR Supervisor, or DIR-certified provider under the direction of a DIR QHP or Supervisor.
96168 EP	Guidance services to a family with an autistic child with the child present; each additional 15 minutes; 14 units; DIR QHP, DIR Supervisor, or DIR-certified provider under the direction of a DIR QHP or Supervisor.
96170 EP	Guidance services to a family with an autistic child; initial 30 minutes; 1 unit; DIR QHP, DIR Supervisor, or DIR-certified provider under the direction of a DIR QHP or Supervisor.
96171 EP	Guidance services to a family with an autistic child without the child present; each additional 15 minutes; 14 units; DIR Supervisor or DIR-certified provider under the direction of a DIR QHP or Supervisor.

Provider education and credential modifiersModifier

HM	Less than Bachelor's degree; HS diploma/Associate's degree reimbursement modifier.
HN	Bachelor's degree reimbursement modifier.
HO	Master's degree reimbursement modifier.
HP	Doctoral/PhD degree reimbursement modifier.

Concurrent billing combinationsCPT

96158EP-96159EP	May be billed concurrently with 96170 EP and 96171 EP.
96164EP-96165EP	May be billed concurrently with 96170 EP and 96171 EP.
96170EP-96171EP	May be billed concurrently with 96158 EP, 96159 EP, 96164 EP, and 96165 EP.
96156EP26	May be billed concurrently with 96158 EP, 96159 EP, 96164 EP, 96165 EP, 96167 EP, 96168 EP, 96170 EP, or 96171 EP.

96156 EP authorization guidance

Code96156 EP

Unit structure1 unit per diem

Authorization guidanceUp to 6 units per 6-month authorization period

QHP supervision

Supervision timeMinimum 1 hour and maximum 2 hours per week

Coding-grid units

Authorization and Documentation Requirements

Prior Authorization

Initial DIR Authorization Required

Obtain authorization for the initial course of DIR intervention services when the individual has ASD and the initial medical-necessity criteria are met. Submit the assessment, person-centered treatment plan, supporting functional assessments, and documentation that services will be delivered by an appropriately licensed or certified provider; for EPSDT billing, preset limits must be overridden when individual medical necessity supports additional services.

Submit the initial assessment and treatment plan for authorization before initiating the initial course of DIR services.
Use CPT 96156 with modifier EP for the initial assessment and treatment-plan development or reassessment: 1 per diem, with a suggested limit of up to 6 units per 6-month authorization period.
The allowable provider specialty is a licensed, DIR-certified QHP (DIR QHP).
EPSDT services are based on individual medical necessity; suggested limits are guidance only and must be overridden when medically necessary based on the individual's needs.

Prior Authorization

Continued-Stay Authorization

DIR/Floortime Background

Developmental, Individual-Differences, and Relationship-Based (DIR) intervention is a developmental model focused on social-emotional development, individual differences, and the relationship between the child and caregiver. DIR uses shared affective experiences and increasingly complex interactions to support communication, attention, social skills, memory, academics, and reduction of problem behavior in children with autism spectrum disorder.

Acronyms and Terminology

DIR

Full nameDevelopmental, Individual-differences, and Relationship-based model

PurposeProvides a foundational framework for understanding human development

Core conceptsExplains the critical role of social-emotional development from birth throughout the lifespan and recognizes that each person perceives and interacts with the world differently

EPSDT

AcronymEPSDT

DefinitionEarly and Periodic Screening, Diagnostic and Treatment

Policy context

DIR/Floortime Intervention

DIR/Floortime / Developmental Individual-Difference Relationship-Based intervention

DIR/Floortime is a developmental intervention approach focused on social-emotional development, individual differences, and the relationship between the child and caregiver.

DIR/Floortime developmental intervention: DIR services may be covered for an individual with ASD when diagnosis, functional-assessment, treatment-plan, measurable-goal, caregiver-training, progress, and qualified-provider requirements are met.

Services may be provided in the therapist's office, a community setting, or the child's home.

Policy Summary

PayerWellpoint

PolicyDevelopmental Individual-Difference Relationship-Based (DIR) UM Guideline

Policy CodePolicy N/A

Change TypeNon-material revision

Effective DateJul 1, 2020

Last ReviewOct 7, 2021

Next Review DateN/A

Key ActionSubmit an updated treatment plan generally every 6 months for continued DIR treatment.

SourceLink

On This Page

Goal-level documentation: For each goal, the record documents progress relative to baseline, anticipated achievement timeline, estimated mastery date, generalization plan, family education and caregiver behaviors to be used outside treatment, and transition or discharge planning.

Minimum 4 and up to 8 units per calendar week for each supervisee

Group-led sessions

Session typeGroup-led sessions

Minimum size2 individual patients

Maximum size8 individual patients

96159 EP

Code96159 EP

ServiceBehavior treatment by protocol

Additional-unit limitUp to 30 additional 30-minute units

96165 EP

Code96165 EP

ServiceGroup-led sessions for a maximum of 8 individual patients

Additional-unit limitUp to 22 additional 15-minute units

96168 EP and 96171 EP

Codes96168 EP and 96171 EP

ServiceAdditional family guidance services in 15-minute increments

Additional-unit limitUp to 14 additional 15-minute units

FFS reimbursement by provider education

HM modifier70% of QHP rates; high school diploma or associate's degree

HN modifier80% of QHP rates; bachelor's degree

HO modifier85% of QHP rates; master's degree

HP modifier90% of QHP rates; doctoral level

For continued authorization, demonstrate that the individual continues to meet the initial-course criteria and submit an updated person-centered treatment plan, generally every 6 months or as required by state mandate. Continued treatment must be supported by documented clinically significant progress and ongoing medical necessity.

Submit the updated treatment plan at least every 6 months, or more frequently when required by a state mandate.
Include age- and impairment-appropriate goals and measures of progress for social, communication, language, adaptive-functioning, and specifically targeted behavioral deficits.
Document an interim progress assessment at least every 6 months and developmental status using standardized assessments no less frequently than every 6 months.
Review direct-treatment hours regularly and adjust them to the individual's behavioral targets and key functional skills based on assessment results.
For continued treatment, document progress relative to baseline, anticipated achievement timelines, estimated mastery, generalization, and transition or discharge planning for each goal.

Documentation Required

Initial Assessment and Treatment-Plan Documentation

The initial submission must establish ASD diagnosis and medical necessity through a complete, person-centered treatment plan. Documentation must address the individual's functional needs and show that the proposed DIR services are appropriate for the individual's age and impairments.

Include an ASD diagnosis made by a licensed medical professional or other qualified healthcare professional consistent with state licensing requirements.
Address identified behavioral, physical, psychological, family, and medical concerns.
Include measurable, objective goals based on standardized assessments, with baseline measurements, progress to date, and an anticipated achievement timeline based on initial and interim assessments.
Document completed assessments of physical, motor, language, social, and adaptive functions.
Document that DIR services will be delivered by an appropriately licensed or certified provider under applicable state law and benefit-plan requirements.

Documentation Required

Required Elements for Each Treatment Goal

The treatment plan must translate identified deficits into age-appropriate, measurable targets and specify how progress will be evaluated and supported across settings. Each target must include caregiver participation and the elements needed to achieve, generalize, and transition from the goal.

Define goals addressing deficient social, communication, language, or adaptive functioning relative to age-expected norms and include objective measures.
Document family education and training, including the behaviors parents or caregivers are expected to demonstrate and use outside treatment, such as at home or in the community; training may use written materials, workshops, or websites.
For each goal, include baseline or progress-to-date measures, the anticipated timeline for achievement based on initial and interim assessments, and an estimated date of mastery.
Include a plan for generalization across people, settings, or activities.
Include transition and discharge planning.
Update each goal's progress relative to baseline in continued-stay submissions.

Documentation Required

Continued-Stay Progress Documentation

Continued-stay documentation must demonstrate measurable progress toward the treatment-plan goals and ongoing developmental need. Submit assessments and plan updates at the required interval, with sufficient detail to support continued authorization.

Provide an interim progress assessment at least every 6 months based on clinical progress toward treatment-plan goals.
Provide standardized developmental assessments no less frequently than every 6 months.
Measure progress in social skills, communication skills, language skills, adaptive functioning, and the specific behaviors or deficits targeted.
Document family education and training, including caregiver behaviors to be demonstrated and utilized outside the treatment setting.
Review and adjust direct-treatment hours regularly to reflect assessment results and the treatment plan.

Documentation Required

Qualified Provider and Credentialing Documentation

Developmental Services must be assessed and planned by a Qualified Healthcare Professional (QHP) who is qualified to diagnose ASD or, after diagnosis, to determine developmental-service need and develop or supervise the treatment plan. The QHP developing a plan for a specific developmental model must have specialized training and the required model-specific credentials.

The diagnosing QHP and the QHP developing or supervising the treatment plan may be different professionals.
Document QHP licensure, education, training, scope-of-practice qualification, and any required state or benefit-plan credentials.
For DIR services, the treating or supervising QHP must have appropriate DIR/developmental-model training and credentials; recognized organizations include ICDL, Profectum Foundation, The PLAY Project, and the Greenspan Floortime Approach.
For other listed developmental models, credentialing examples include the RDI Professional Training Program, approved infant mental-health endorsements, and ESDM Certified status, as applicable to the model used.
For CPT 96156 EP, use a licensed and DIR-certified QHP (DIR QHP).

Denial Risk

Denial Risk: Criteria Not Met or No Significant Progress

Where DIR services are subject to clinical-criteria review, services are not covered and are not medically necessary when the applicable criteria are not met or when an interim standardized assessment does not document clinically significant progress in a required developmental domain.

Coverage may be denied when any applicable initial or continued-stay criterion is not satisfied or required documentation is missing.
Coverage may be denied when no clinically significant progress is documented in adaptive functioning, communication skills, language skills, or social skills.
Providers should submit standardized interim assessments and complete treatment-plan updates to support continued medical necessity.

EPSDT services are provided to meet individual medical necessity

QHP

AcronymQHP

DefinitionQualified Healthcare Professional

Role in this policyProvides or directs covered DIR services and treatment supervision

ASD

AcronymASD

DefinitionAutism Spectrum Disorder

Policy relevanceThe covered population addressed by the DIR services guideline

CPT

AcronymCPT

DefinitionCurrent Procedural Terminology

Use in this policyIdentifies the procedure codes used for DIR assessment, treatment, supervision, group sessions, and family guidance

DIR

TermDIR

Expanded terminologyDevelopmental Individual-difference Relationship-based

Intervention contextRefers to developmental services and the DIR/Floortime intervention model

DMAI

AcronymDMAI

DefinitionDevelopmental Models of Autism Intervention

SubjectDevelopmental intervention models for autism

DSM

AcronymDSM

DefinitionDiagnostic and Statistical Manual of Mental Disorder

UseA diagnostic reference identified in the policy acronyms

EPSDT

TermEPSDT

Expanded terminologyEarly and Periodic Screening, Diagnostic and Treatment

Coverage principleMedically necessary services cannot be limited under EPSDT

IMH

AcronymIMH

DefinitionInfant Mental Health

FieldMental health during infancy

NJAIMH

AcronymNJAIMH

DefinitionNew Jersey Association for Infant Mental Health

Organization typeNew Jersey association focused on infant mental health

NJFC

AcronymNJFC

DefinitionNew Jersey Family Care

Program nameNew Jersey Family Care

QHP

TermQHP

Expanded terminologyQualified Healthcare Professional

Policy roleA qualified professional who provides or directs covered DIR services