CurrentWest Virginia Bureau for Medical Services (Department of Human Services)Policy 519.23.1

Applied Behavior Analysis (ABA) — Coverage Criteria

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Governs coverage, provider qualifications, prior authorization, assessment, and billing rules for ABA services provided to West Virginia Medicaid members (children with ASD). Affects enrolled ABA providers and managed care/utilization management reviewers.

Policy Summary

PayerWest Virginia Bureau for Medical Services (Department of Human Services)

PolicyApplied Behavior Analysis (ABA) — Coverage Criteria

Policy CodePolicy 519.23.1

Change TypeNo material changes

Effective DateSep 1, 2018

Last ReviewSep 1, 2018

Next Review Date

Key ActionObtain prior authorization with required diagnostic assessment, physician's order, consent/assurances, and adaptive skills assessment before delivering ABA services.

SourceLink

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CurrentWest Virginia Bureau for Medical Services (Department of Human Services)Policy 519.23.1

Applied Behavior Analysis (ABA) — Coverage Criteria

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Policy Summary

PayerWest Virginia Bureau for Medical Services (Department of Human Services)

PolicyApplied Behavior Analysis (ABA) — Coverage Criteria

Policy CodePolicy 519.23.1

Change TypeNo material changes

Effective DateSep 1, 2018

Last ReviewSep 1, 2018

Next Review Date

Key ActionObtain prior authorization with required diagnostic assessment, physician's order, consent/assurances, and adaptive skills assessment before delivering ABA services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18 mo–20 yreligible member age range

ASD before 8diagnosis timing req

H0031: 1/yrinitial assessment limit

40 wk / 8 dweekly/24h cap

15 minservice unit

Coverage and Medical Necessity

Medical Necessity / Eligibility Criteria

Covered when ALL of the following are met

Eligibility: Member is Medicaid-enrolled child aged 18 months through 20 years with primary diagnosis of Autism Spectrum Disorder rendered prior to the child's 8th birthday and referred for services identified during an EPSDT encounter

Diagnostic evidence: Submission of a current diagnostic assessment completed within previous 24 months by a qualifying diagnostic provider documenting DSM/ICD ASD diagnosis, severity level, and relevant specifiers; initial qualifying diagnostic must have been rendered prior to age 824 months

Providers must document diagnosis prior to 8th birthday

Medical necessity and plan: Prior authorization review must determine medical necessity based on an implemented ABA plan, documented baseline adaptive and maladaptive behaviors, ABA service intensity appropriate to assessed functioning, and measurable indicators of behavior change from submitted data

Ongoing reviews required to maintain authorization; documentation of progress expected

Non-duplication: Services must not supplant or duplicate educational services or other funding sources; services that are educational in nature cannot be authorized

Consent/IEP documentation may be requested to avoid duplication

Initial Functional Assessment (H0031) Criteria

Assessment services covered when ALL of the following are met

Assessment provider: Initial Functional Assessment (H0031) must be performed by BCBA, BCBA-D, or BCaBA

Maximum one per year; face-to-face 1:1

Assessment prior auth: Prior authorization is required for H0031 and the service is billed as 1 assessment = 1 event1 per year

Refer to Utilization Management Guidelines

Treatment and Skills Training Coverage Criteria

Treatment services covered when ALL of the following are met

Provider qualifications: H0032 and H2012 must be delivered by BCBA/BCBA-D; H2019 must be delivered by BCaBA; RBTs may provide direct implementation under supervision as permitted by provider qualifications

Staff credentials required per code definitions in provider qualifications

Prior authorization and limits: All treatment codes require prior authorization; H0032, H2012, H2019, H2014 and H2014 variants may be combined up to a maximum of 40 hours per week and/or 8 hours within a 24-hour period40 hours/week; 8 hours/24h

Service week defined as Sunday 12:00 am thru Saturday 11:59 pm

Service setting and ratio: H2012 and H2019 are face-to-face 1:1 services; H2014 is a face-to-face group service with a 1 staff to 2–3 members ratio

Group skills training elsewhere limited to 4 members per staff

Initial/General Coverage

Covered when ALL of the following are met:

General coverage criteria: Service consists of therapeutic activities focused on elementary/basic skills to improve or preserve member functioning as identified in the service plan and targets members who require direct prompting or direct intervention by a provider

Supported by service definition and target population

Setting and group size: When provided in a group context, groups must be limited to four members per staff; H2014 specifically denotes face-to-face 1:2-3 group servicegroup size <= 4 per staff

Provider qualifications: Group services require BCBA, BCBA-D, or BCaBA staff; individual H2014U4/H2014U5 direct contact is by RBT under supervision and BCBA/BCBA-D/BCaBA may bill for the service

See provider qualifications in chapter 519.23.4

Services that are educational in nature and therefore duplicative of an Individualized Education Program (IEP) are not authorized. The policy requires documentation of available natural supports including educational staff and any non-duplicating services available through an IEP to ensure services do not supplant educational services. Providers must not bill Medicaid for services that are the responsibility of educational authorities.

Requests submitted by parents or guardians are not accepted for prior authorization, and services delivered by family members or other non-credentialed individuals are not a covered benefit. Additionally, back-dating of prior authorizations is prohibited and retrospective review requests will be denied.

Recreational trips, mall visits, recreational or leisure activities, activities that function as reinforcements for behavioral management programs, and social events are explicitly not therapeutic and cannot be billed as Skills Training and Development services. Such activities do not meet the service definition and will be excluded from coverage.

Services that supplant or duplicate educational services or those funded by other sources are not medically necessary and cannot be authorized. The policy requires submission of documentation demonstrating that proposed ABA services do not duplicate supports available through an IEP or other funding streams.

Services provided by non-credentialed individuals, including family members, are not covered. Providers must obtain prior authorization and meet all credentialing and documentation requirements; failure to do so (including retrospective/back-dated authorizations) will result in denial and the provider cannot bill the member for those services.

The use of Skills Training and Development to deliver non-therapeutic recreational or leisure activities or to host social events is not considered medically necessary. Skills Training and Development must consist of structured, therapeutic activities focused on elementary and adaptive skills as described in the service plan; billing for leisure or social events as therapy is not permitted.

Billing Codes, Units, and Limits

Assessment CodesHCPCSCovered

H0031

Initial Functional Assessment by Non-Physician (1 assessment = 1 event); Face-to-Face 1:1; Prior Authorization required; Maximum one per year; Staff: BCBA/BCBA-D/BCaBA

Plan Development CodesHCPCSCovered

H0032

Development of ABA Plan; 15-minute unit; Face-to-Face 1:1; Prior Authorization required; May be combined with H2012, H2019, H2014, H2014U4, H2014U5 up to 40 hrs/week and/or 8 hrs/24h

Individual ABA Treatment CodesHCPCSCovered

H2012	Behavioral health day treatment, per hour; Face-to-Face 1:1; Prior Authorization required; Staff: BCBA/BCBA-D; May be combined with H0032, H2019, H2014 variants up to 40 hrs/week and/or 8 hrs/24h
H2019	Therapeutic behavioral services, per 15 minutes; Face-to-Face 1:1; Prior Authorization required; Staff: BCaBA; Implementation as documented in preauthorized ABA treatment plan

Group Skills Training CodesHCPCSCovered

H2014

Skills training and development, group; 15-minute unit; Face-to-Face 1:2-3; Prior Authorization required

Referenced combinable codes/modifiersmixed

H2014U4	Modifier/code variant referenced for combination use (documented as combinable up to weekly limit)
H2014U5	Modifier/code variant referenced for combination use (documented as combinable up to weekly limit)

Covered CPT/HCPCS CodesHCPCSCovered

H2014

ABA - Group Skills Training and Development (Face-to-Face 1:2-3 Service)

Covered CPT/HCPCS CodesHCPCSCovered

H2014U4	ABA - Individual Skills Training and Development (Face-to-Face 1:1 Service)
H2014U5	ABA - Individual Skills Training and Development (Face-to-Face 1:1 Service)

Combined service weekly and 24-hour cap — Maximum of 40 hours per week and/or 8 hours within a 24-hour period

LimitMaximum of 40 hours per week and/or 8 hours within a 24-hour period

Applicable codesH0032, H2012, H2019, H2014, H2014U4, H2014U5 (may be combined up to this cap)

Service week definedSunday 12:00 am thru Saturday 11:59 pm

Weekly and daily ABA service limit — Maximum combined of up to 40 hours per week and/or eight hours within a 24-hour period

LimitMaximum combined of up to 40 hours per week and/or eight hours within a 24-hour period

Prior Authorization, Documentation, and Billing Rules

Prior Authorization

Prior authorization required for all ABA service codes

Prior authorization (PA) must be obtained before any ABA service is rendered for all listed ABA procedure codes (H0031, H0032, H2012, H2019, H2014, H2014U4, H2014U5). PA requests must reference and comply with the Utilization Management Guidelines.

Applicable codes: H0031, H0032, H2012, H2019, H2014, H2014U4, H2014U5.
PA must be obtained prior to service provision; see Utilization Management Guidelines for submission details.

Prior Authorization

PA required for H2014 and H2014U4/H2014U5

Prior authorization is required for H2014, H2014U4, and H2014U5 and requests must follow the Utilization Management Guidelines for those codes.

Codes H2014 (group) and H2014U4/H2014U5 (individual) require PA and are subject to the same combination and weekly/24-hour limits as other ABA treatment codes.

Service Setting and Level of Care

Clinical Principles and Service-Level Rules

ABA clinical principles

ABA clinical approach and assessment foundations

Individualization: ABA interventions must be individualized to the client's strengths, needs, and preferences based on interviews, functional assessments, observation, and data collection; caregiver training and oversight are included

Data-driven reviews: Medical necessity is maintained through ongoing clinical progress reviews with documentation of treatment progress shown by measurement and data analysis reflecting behavior change goals

Indicators of behavior change are expected to be submitted during PA reviews

ABA-specific criteria

ABA service-level rules and definitions

Direct implementation and supervision:

Skills Training and Development

Skills training: Skills Training and Development targets basic and adaptive daily living and social skills through structured individual and group activities; services are therapeutic, not recreational

Young children: group services limited to <=4 hours/day and <=4 days/week

Skills Training and Development

Modality: Skills training: Structured therapeutic activities focused on personal hygiene, managing living space, manners, sexuality, social appropriateness, daily living skills, communication, mobility, problem solving, and parent-child interactions

Group when used must follow size limits; targets members needing direct prompting/intervention

Assessment and Combined-Service Limits

Initial Functional Assessment (H0031) — 1

Service codeH0031

Unit/Limit1 Assessment = 1 Event; Maximum of one per year per member

Level of serviceFace-to-Face 1:1; Staff must be BCBA, BCBA-D, or BCaBA

Combined ABA treatment services (H0032, H2012, H2019, H2014 variants) — 40 hours

Combined weekly cap40 hours per week

Included codesH0032, H2012, H2019, H2014 (and variants H2014U4, H2014U5)

Service unit examples

Key Terms

ABA — Applied Behavior Analysis definition

DefinitionApplied Behavior Analysis (ABA): application of behavioral science principles to improve socially significant behaviors through individualized, data-driven interventions.

Key componentsIndividualized intervention, functional assessment, direct observation, data collection, caregiver training and oversight

GoalImprove functional skills and reduce problem behaviors by addressing skill deficits and maladaptive behaviors

Initial Functional Assessment (H0031) — definition and purpose

Code & nameH0031 — Initial Functional Assessment

PurposeInitial evaluation or reassessment to determine needs, strengths, functioning levels, mental status, and/or social history; includes administration/scoring of functional assessment instruments to determine medical necessity and level of care

Policy Background

Applied Behavior Analysis (ABA) is an individualized, data-driven intervention approach designed to improve or preserve a member's functional skills and reduce problem behaviors. ABA plans are developed from comprehensive diagnostic information and functional assessments that document baseline adaptive and maladaptive behaviors, identify behavior targets for change, and specify service intensity matched to assessed functioning.

ABA services typically require direct, face-to-face implementation and ongoing measurement of behavior change. Interventions include caregiver training and use of natural supports, and must follow best-practice standards (including those of the Behavior Analyst Certification Board) with periodic data-driven reviews to demonstrate clinical progress and medical necessity.

Policy Revision History

2018-09-01policy_effectiveLatest

New chapter 519.23 'Applied Behavior Analysis' published and became effective, establishing member eligibility, medical necessity criteria, provider qualifications, prior authorization and service definitions for ABA services.

Policy Summary

PayerWest Virginia Bureau for Medical Services (Department of Human Services)

PolicyApplied Behavior Analysis (ABA) — Coverage Criteria

Policy CodePolicy 519.23.1

Change TypeNo material changes

Effective DateSep 1, 2018

Last ReviewSep 1, 2018

Next Review Date

Key ActionObtain prior authorization with required diagnostic assessment, physician's order, consent/assurances, and adaptive skills assessment before delivering ABA services.

SourceLink

On This Page

Codes H0032, H2012, H2019, H2014, H2014U4, and H2014U5 may be combined up to a maximum of 40 hours per week and/or eight hours within a 24-hour period

<=40 hours/week and <=8 hours/24-hr

Service week defined Sunday 12:00 am thru Saturday 11:59 pm

Age-appropriate care for young children: For children under age five, group therapeutic activities must be age- and developmentally appropriate, promote skill acquisition, support family routine, and not be provided in group settings for more than four hours per day or more than four days per week<=4 hours/day and <=4 days/week for group services for children <5

Codes covered by this limitH0032, H2012, H2019, H2014, H2014U4, H2014U5

Service week definitionSunday 12:00 am thru Saturday 11:59 pm

Note

Ensure complete PA submission to avoid denials

Providers must ensure PA submissions include all required documentation described in policy; incomplete or unspecified requests that do not include the required supporting documents risk denial.

Ensure PA references applicable Utilization Management Guidelines and service combination limits (≤40 hours/week and ≤8 hours/24-hr).
Do not submit back-dated or retrospective PA requests.

Note

Follow provider qualification and participation requirements

Providers must follow the specific provider participation and credentialing rules: only BCBA, BCBA-D, BCaBA (with supervisory relationships) may perform and bill for specified assessment and treatment activities as defined by the chapter.

BCBA/BCBA-D/BCaBA are required for assessments (H0031) and plan development (H0032); BCBA/BCBA-D for H2012; BCaBA for H2019; RBTs provide direct contact only under supervision for H2014U4/H2014U5.
Enroll and maintain BACB certification in good standing and meet Provider Manual participation requirements.

Documentation Required

Required documentation to support prior authorization

PA requests must include the qualifying diagnostic assessment establishing ASD diagnosis prior to the member's 8th birthday (completed within previous 24 months), a comprehensive diagnostic assessment (within previous 24 months), the annual Physician's Order for ABA services, a Consent to Release/Statement of Assurances, and an annual approved assessment of adaptive skills.

Diagnostic evidence: qualifying diagnostic assessment documenting DSM/ICD ASD diagnosis and specifiers; initial qualifying diagnostic must have been rendered prior to age 8 and completed within the last 24 months.
Include Annual Physician's Order for ABA services.
Include Consent to Release Information and Bill Medicaid or Statement of Assurances; UM vendor/MCO may request IEP-related documentation when needed.
Include an annually approved assessment of adaptive skills.

Documentation Required

Submit Treatment Plan and Statement of Assurances

Treatment Plan/Intervention Service Plan must be a written plan developed pursuant to a comprehensive evaluation or reevaluation and must include a Statement of Assurances that services do not duplicate existing services.

Plan must identify treatment goals and be developed by the treatment team (member/guardian, case manager, providers) consistent with comprehensive evaluation.
Submit the Statement of Assurances confirming non-duplication of services; UM vendor or MCO may request supporting IEP or education-agreement documents.

Denial Risk

Do not submit retrospective requests; non‑credentialed providers not covered

Do not submit retrospective (back-dated) authorization requests; PA requests received from parents/guardians will not be accepted; services provided by family members or other non-credentialed individuals are not covered and will be denied.

Back-dated/retrospective review requests will be denied.
Requests from parents/guardians are not accepted — PA must be submitted by enrolled providers.
Family members and non-credentialed individuals providing ABA services are not covered benefits.

Denial Risk

Do not bill recreational or non-therapeutic activities as Skills Training

Billing non-therapeutic activities — including recreational trips, mall visits, leisure activities, reinforcements for behavioral programs, and social events — as Skills Training and Development may trigger denial and are not considered therapeutic services.

Ensure billed Skills Training and Development services are therapeutic, goal-directed, and documented in the treatment plan; do not bill purely recreational or social events as therapy.
For young children, adhere to group limits (≤4 hours/day and ≤4 days/week) and ensure activities promote skill acquisition and family routine support.

Registered Behavior Technicians (RBTs) provide direct implementation under close supervision of BCBA/BCBA-D/BCaBA; BCBAs and BCaBAs design and may bill for services

Group vs Individual codes: H2014 is for group (face-to-face 1:2-3); H2014U4 and H2014U5 are individual face-to-face 1:1 services; service unit for these codes is 15 minutes15 minutes

H0032 = 15 minutes; H2012 = 60 minutes; H2019/H2014 = 15 minutes

Combined ABA treatment services — 8 hours

Daily (24-hour) cap8 hours within a 24-hour period

Applies to codesH0032, H2012, H2019, H2014, H2014U4, H2014U5

Service week definitionSunday 12:00 am thru Saturday 11:59 pm

combined ABA services (H0032, H2012, H2019, H2014, H2014U4, H2014U5) — 40 hours

Weekly cap40 hours per week

Codes includedH0032, H2012, H2019, H2014, H2014U4, H2014U5

NoteMay be billed in combination up to the weekly cap per Utilization Management Guidelines

combined ABA services (H0032, H2012, H2019, H2014, H2014U4, H2014U5) — 8 hours

24-hour cap8 hours within a 24-hour period

Applies toH0032, H2012, H2019, H2014, H2014U4, H2014U5 when combined

Service weekSunday 12:00 am thru Saturday 11:59 pm

group Skills Training and Development — 4 members per staff

Group ratioMaximum 4 members per staff for Skills Training and Development group sessions

Relevant codeH2014 (group Skills Training and Development)

TargetMembers requiring direct prompting or direct intervention by a provider

group therapeutic activities for young children — 4 hours/day; 4 days/week

Young children group limitNo more than 4 hours per day and no more than 4 days per week for group therapeutic activities for children under age 5

PurposeEnsure services are age- and developmentally-appropriate and support family routine

Applies toSkills Training and Development group services for young children

Limits & staffingFace-to-Face 1:1; Prior authorization required; Maximum one per year; Staff must be BCBA, BCBA-D, or BCaBA

Skills Training and Development — definition

DefinitionSkills Training and Development: a combination of structured individual and group activities to improve or preserve daily living and basic adaptive skills for members with basic skill deficits.

ExamplesPersonal hygiene, managing living space, manners, social appropriateness, daily living skills, parent-child interactions, communication, mobility, problem solving

Group rulesWhen in group context, group must be limited to four members per staff; not therapeutic when used for recreational/leisure activities

RBT — Registered Behavior Technician definition

DefinitionRegistered Behavior Technician (RBT): a paraprofessional credentialed by the BACB who practices under close supervision of a BCBA/BCBA-D/BCaBA and is primarily responsible for direct implementation of behavior-analytic services.

ScopeRBT does not design interventions or assessments; supervisor determines RBT tasks based on training and competence; supervising BACB certificant is responsible for RBT's work

Use in billingDirect contact by RBT is permitted for H2014U4/H2014U5 under supervision; BCBA/BCaBA may bill for the service

BCBA / BCaBA — definitions

BCBABoard Certified Behavior Analyst (BCBA): independent practitioner who conducts behavioral assessments (including functional analyses), provides analytic interpretations, designs and supervises interventions, and supervises BCaBAs and RBTs.

BCaBABoard Certified Assistant Behavior Analyst (BCaBA): designs and oversees interventions, may teach others to implement interventions under BCBA supervision, and practices under mandatory BCBA supervision; competency and supervision must be verified annually.

Professional standardsWV Medicaid follows the BACB Professional and Ethical Compliance Code for Behavior Analysts