Autism Spectrum Disorder Services for EPSDT

General Information 

This manual is designed to be used in conjunction with other sections of the Utah Medicaid Provider Manual, such as Section I: General Information of the Utah Medicaid Provider Manual.

The information in this manual represents available services when medically necessary. Services may be more limited or may be expanded if the proposed services are medically appropriate and are more cost effective than alternative services.

General Policy

Autism Spectrum Disorder (ASD) related services are non-covered benefits for Medicaid beneficiaries.

ASD related services are only available under the Early Periodic Screening, Diagnosis, and Treatment program.

The Early Periodic Screening, Diagnostic and Treatment (EPSDT) Program is a program that offers comprehensive and preventive health care services for individuals under age 21 who are enrolled in Traditional Medicaid (also known in Utah as the Child Health Evaluation and Care (CHEC) program).

ASD related services may include diagnostic assessments and evaluations.

ASD related services may include therapies such a physical therapy, occupational or speech therapy.

ASD related services may also include services that are rooted in principles of applied behavior analysis (ABA). ABA is a well-developed discipline based on a mature body of scientific knowledge and established standards for evidence-based practice. ABA focuses on the analysis, design, implementation and evaluation of social and other environmental modifications to produce meaningful changes in behavior. ABA is a behavioral health treatment that is intended to develop, maintain, or restore, to the maximum extent attainable, the functioning of a child with ASD. ABA-based therapies are based on reliable empirical evidence and are not experimental or investigational.

Fee-For-Service or Managed Care

This manual provides information regarding Medicaid policy and procedures for fee-for-service Medicaid members. This manual is not intended to provide guidance to providers for Medicaid members enrolled in a managed care plan (MCP). A Medicaid member enrolled in an MCP (health, behavioral health or dental plan) must receive services through that plan with some exceptions called “carve-out services,” which may be billed directly to Medicaid. If a Medicaid member is enrolled in a MCP, a fee-for-service claim will not be paid unless the claim is for a “carve-out service.”

Eligibility and plan enrollment information for each member is available to providers from these sources:

• The Eligibility Lookup Tool: https://medicaid.utah.gov/eligibility
• AccessNow: (800) 662-9651

Definitions

Applied Behavioral (ABA)

A well-developed discipline based on a mature body of scientific knowledge and established standards for evidence-based practice. ABA focuses on the analysis, design, implementation and evaluation of social and other environmental modifications to produce meaningful changes in behavior. ABA is a behavioral health treatment that is intended to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual with ASD. Examples of ABA-based interventions may include but are not limited to: Discrete Trial Training, Direct Instruction, Prompting, Shaping and Fading, Generalization, Incidental Teaching, Self-Management, Reinforcement, Antecedent-Based Interventions, Pivotal Response Training, Schedules, Scripting, Picture Exchange Communication System (PECS), Modeling and Social Skills Package.

Autism Spectrum Disorder (ASD)

Autism spectrum disorder is characterized by: Persistent deficits in social communication and social interaction across multiple contexts; restricted, repetitive patterns of behavior, interests, or activities; Symptoms must be present in the early developmental period (typically recognized in the first two years of life); and, symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

Behavior Analyst Certification Board (BACB)

The BACB is a nonprofit 501(c)(3) corporation established to meet professional credentialing requirements for behavior analysts.

Behavior Analyst in Training

Individuals in the process of earning a master’s degree from an accredited graduate school and who is enrolled in BCBA coursework and is in the process of completing their hours of supervised practice.

Board Certified Assistant Behavior Analyst (BCaBA)

Bachelor’s prepared individuals who meet the professional credentialing requirements of the Behavior Analyst Certification Board and licensed in the State of Utah as per UCA 58-61. (Hereafter referred to as assistant behavior analyst).

Board Certified Behavior Analyst (BCBA)

Master’s prepared individuals who meet the professional credentialing requirements of the Behavior Analyst Certification Board (hereafter referred to as behavior analyst) and licensed in the State of Utah as per UCA 58-61.

Board Certified Behavior Analyst-Doctorate (BCBA-D)

Doctoral prepared individuals who meet the professional credentialing requirements of the Behavior Analyst Certification Board (hereafter referred to as behavior analyst) and licensed in the State of Utah as per UCA 58-61.

Psychologist:

Individuals who have earned a doctorate in psychology from an accredited graduate school and licensed in the State of Utah as per UCA 58-61.

Registered Behavior Technician (RBT)

Individuals at least 18 years of age, who have received specific formal training prior to delivering ABA treatment and who meet the Registered Behavior Technician credentialing requirements established by the Behavior Analyst Certification Board.

Wasatch Front

Davis, Salt Lake, Utah and Weber Counties

Provider Participation Requirements

Provider Enrollment

Medicaid payment is made only to providers who are actively enrolled in the Utah Medicaid Program. Refer to provider manual, Section I: General Information of the Utah Medicaid Provider Manual for provider enrollment information.

Provider Credentials

General

For purposes of authorizing ASD related services, an ASD diagnosis is required prior to beginning services. Clinicians authorized under the scope of their licensure to render diagnoses and trained on the use of the assessment tools specified in Section 3. Member Eligibility 3-1 Establishing Medical Necessity, of this document may render the ASD diagnosis.

ABA services must be rendered by a psychologist or behavior analyst, or under the direction of a psychologist or behavior analyst.

Only a psychologist or a behavior analyst can design and supervise an ABA services treatment program.

Psychologists:

• Be licensed as a psychologist under Utah Division of Occupational and Professional Licensing[1]Utah Division of Occupational and Professional Licensing[1]Behavior analysts are required to submit licensure applications to the Utah Division of Occupational and Professional Licensing on or before November 15, 2015.;
• Provide proof of current licensure and have no sanctions or disciplinary actions;
• In conjunction with the standard Medicaid Provider Agreement, submit a signed ASD Related Services Attachment A form;
• Be personally covered by professional liability insurance to limits of $1,000,000 per occurrence, $1,000,000 aggregate;
• Ensure the all individuals working under the psychologist’s supervision are covered by professional liability insurance to limits of $1,000,000 per occurrence, $1,000,000 aggregate; and
• Have a completed criminal background check to include federal criminal, state criminal and sex offender reports;
  • Criminal background checks must be current, within a year prior to the Medicaid provider enrollment application; and
  • Criminal background checks must be performed at least every three years thereafter.

The psychologist is responsible for retaining compliance records for the items listed above.

Behavior Analysts (BCBA-D and BCBA)

• Be licensed as a behavior analyst under Utah Division of Occupational and Professional Licensing;
• Provide proof of certification by the Behavior Analyst Certification Board and have no sanctions or disciplinary actions on their BCBA-D or BCBA certification and/or state licensure;
• In conjunction with the standard Medicaid Provider Agreement, submit a signed ASD Related Services Attachment A form;
• Be covered by professional liability insurance to limits of $1,000,000 per occurrence, $1,000,000 aggregate;
• Ensure that all individuals working under the behavior analyst’s supervision are covered by professional liability insurance to limits of $1,000,000 per occurrence, $1,000,000 aggregate; and
• Have a completed criminal background check to include federal criminal, state criminal and sex offender reports;
  • Criminal background checks must be current, within a year prior to the Medicaid provider enrollment application; and
  • Criminal background checks must be performed at least every three years thereafter.

The behavior analyst is responsible for retaining compliance records for the items listed above.

Behavior Analysts in Training:

Reimbursement for services provided by a behavior analyst in training shall only be submitted to Medicaid when the services were provided under the direction of a behavior analyst and must meet the following requirements:

• Must be enrolled in a behavior analysis course sequence approved by the BACB at an accredited institution of higher education;
• Must be currently enrolled in BCBA coursework;
• Must have completed at least 500 hours of supervised practice performing BCBA duties;
• Complete and submit the Limited Medicaid Provider Agreement;
• Completion of a criminal background check to include federal criminal, state criminal and sex offender reports;
  • Criminal background checks must be current, within a year prior to the Medicaid provider enrollment application; and
  • Criminal background checks must be performed at least every three years thereafter. 

Behavior analysts in training have twelve months from the end of the semester in which their BCBA coursework was completed to complete remaining, required supervisory hours, BACB certification, and licensure. Behavior analysts in training are not permitted to continue to provide services under this definition indefinitely.

The supervising behavior analyst is responsible for retaining compliance records for the items listed above.

Under the supervision of a psychologist or behavior analyst, the behavior analyst in training may perform clinical and case management support and may assist in oversight of technicians. Behavior analysts in training may also assist the psychologist or behavior analyst in the completion of periodic assessments as well as the development of treatment plans. The supervising BCBA must be present during the periodic assessments and the development of the treatment plans.

Assistant Behavior Analysts (BCaBA)

Assistant behavior analysts shall deliver services only under the direction of a psychologist or behavior analyst and must meet the following requirements:

• Licensure as an assistant behavior analyst under Utah Division of Occupational and Professional Licensing
• Provide proof of certification by the Behavior Analyst Certification Board and have no sanctions or disciplinary actions on their BCaBA certification and/or state licensure; and
• Complete and submit the Limited Medicaid Provider Agreement;
• Completion of a criminal background check to include federal criminal, state criminal and sex offender reports;
  • Criminal background checks must be current, within a year prior to the Medicaid provider enrollment application; and
  • Criminal background checks must be performed at least every three years thereafter. 

Under the supervision of a psychologist or behavior analyst, the assistant behavior analysts may perform clinical and case management support and may assist in oversight of technicians. The assistant behavior analyst cannot complete assessments and reassessments nor develop the treatment plan. The assistant behavior analyst cannot provide greater than fifty percent of behavior analyst level of services for any individual.

The assistant behavior analyst may also provide routine direct intervention. When the assistant behavior analyst provides direct intervention, the provider must not bill for behavior analyst level of services. Billing codes for direct intervention by the assistant behavior analyst or technician must be used.

The supervising psychologist or behavior analyst is responsible for retaining compliance records for the items listed above.

Registered Behavior Technician (RBT)

Registered behavior technicians (technicians) may deliver services under the supervision of a psychologist or behavior analyst and must meet the following requirements:

• Be at least 18 years of age;
• Possess a minimum of a high school diploma or equivalent;
• Complete and submit the Limited Medicaid Provider Agreement;
• Successfully complete a criminal background check to include federal criminal, state criminal and sex offender reports;
  • Criminal background checks must be current, within a year prior to the Medicaid provider enrollment application; and
  • Criminal background checks must be performed at least every three years thereafter; 
• Must possess current Registered Behavior Technician certification or
  • Complete a 40-hour training program (conducted by a BACB certificant) based on the Registered Behavior Technician Task List; and
  • Pass the Registered Behavior Technical Competency Assessment administered by a BACB certificant within 120 days of the employee’s date of hire.

The supervising psychologist or behavior analyst is responsible for retaining compliance records for the items listed above.

Member Eligibility

ABA services are only available under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.

As stated in Section I: General Information of the Utah Medicaid Provider Manual, Verifying Medicaid Eligibility, a Medicaid member is required to present the Medicaid Identification Card before each service, and every provider must verify each member’s eligibility each time before rendering services.

Medicaid eligibility can be verified using AccessNow, Eligibility Lookup Tool, and ANSI 270 and ANSI 271. For detailed information, call Medicaid Information, or go to the Medicaid website at https://medicaid.utah.gov/medicaid-online.

Note: Medicaid staff makes every effort to provide complete and accurate information on all inquiries. However, federal regulations do not allow a claim payment even if the information given to a provider by Medicaid staff was incorrect.

For more information regarding verifying eligibility, refer to provider manual, Section I: General Information of the Utah Medicaid Provider Manual. Verifying Medicaid Eligibility.

Establishing Medical Necessity

In order to receive Applied Behavior Analysis (ABA) services, The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) eligible individuals must have a valid ASD diagnosis. Clinicians authorized under the scope of their licensure and trained on the use and interpretation of the assessment tools listed below may render the ASD diagnosis. Ideally, the diagnostic evaluation process should include an interdisciplinary team approach that includes: (1) health, developmental, socioemotional, and behavioral histories; (2) developmental, adaptive, and/or cognitive evaluation to determine the child’s overall level of functioning; (3) determination of the presence of the DSM-5 criteria for ASD, using standardized measures to operationalize the DSM criteria. Standardized measures should include one of the following ASD diagnostic evaluation instruments: Autism Diagnostic Interview-Revised (ADI-R), Autism Diagnostic Observation Schedule (ADOS), Autism Diagnostic Observation Schedule Second Edition (ADOS-2) or the Prelinguistic Autism Diagnostic Observation Schedule (PL-ADOS).

In cases of children ages two and up to six years in which evaluations are interdisciplinary and include elements 1 & 2 above, consideration may be given to the appropriate use of both parent completed and interactive level 2 ASD screening measures in place of an ASD diagnostic evaluation instrument when DSM-5 criteria can be accurately applied. Examples of appropriate parent completed level 2 ASD screening measures include, but are not limited to, the Social Communication Questionnaire (SCQ) and the Autism Spectrum Rating Scale (ASRS). Examples of examiner-administered appropriate interactive level 2 ASD screening measures include, but are not limited to, the Screening Tool for Autism in Toddlers and Young Children (STAT) and the Autism Mental Status Exam (ASME). The clinician (or interdisciplinary team) performing an ASD evaluation must have advanced training and experience in the diagnostic evaluation of children with ASD. A copy of the medical records that includes the ASD diagnosis, level 2 screening measure, or evaluation tool, and diagnostic results must be submitted with the initial prior authorization request.

For diagnoses rendered using a level 2 ASD screening tool in a multi-disciplinary setting, Section 2 of the Utah Medicaid ASD Diagnostic Confirmation Form must be completed and submitted with the prior authorization request to document the individuals participating in the multi-disciplinary team, the screening tool(s) used and the advanced training/experience received by the clinician rendering the diagnosis.

For diagnoses rendered prior to July 1, 2015, in which an approved diagnostic tool was not used, Section 1 of the Medicaid Diagnostic Confirmation Form must be submitted along with clinical documentation to support the ASD diagnosis. The Medicaid Diagnostic Confirmation Form must be completed by a clinician authorized under the scope of their licensure to render an ASD diagnosis.

Beneficiaries Enrolled in a Managed Care Plan (MCP) or Prepaid Mental Health Plan (PMHP)

For beneficiaries enrolled in a MCP, requests for ASD related medical services including but not limited to physical, occupational and speech therapies will be referred to the MCP.

For beneficiaries enrolled in a PMHP, requests for services related to co-occurring, mental health conditions will be referred to the PMHP.

ASD related diagnostic evaluations are “carve-out” services that are covered under the Medicaid fee-for-service benefit. These serves are not available through a MCP or PMHP.

The ASD related ABA services are “carve-out” services that are covered under the Medicaid fee-for-service benefit. These serves are not available through a MCP or PMHP.

Program Coverage

General

ASD Diagnostic Services

In order to receive ABA services, EPSDT eligible individuals must have a valid ASD diagnosis.

Clinicians authorized under the scope of their licensure to render diagnoses and trained on the use of the assessment tools specified in Section 3, Member Eligibility, 3-1 Establishing Medical Necessity, of this document may render the ASD diagnosis.

Mental Health evaluations and psychological testing performed for the purpose of diagnosing developmental disorders must be reported with the UC modifier appended. These services are considered carved out and will be reimbursed on a fee-for-service basis.

With some exceptions, procedure codes with accompanying criteria and limitations have been removed from the provider manual and are now found on the Medicaid website Coverage and Reimbursement Lookup Tool at: https://medicaid.utah.gov

Examples of Current Procedural Terminology (CPT) codes used for diagnostic testing can be found in the Section 2 Provider Manual – Rehabilitative Mental Health and Substance Use Disorder Services .

Note: It is the responsibility of the clinician to utilize the appropriate billing code for services rendered.

ASD Related Physical, Occupational, and Speech Therapy

ASD related services are only available under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.

For fee-for-service Medicaid members, all ASD related requests for therapy services will be submitted to the CHEC Committee for review and determination of medical necessity.

For Medicaid beneficiaries enrolled in a MCP, all ASD related requests for therapy services must be submitted to the MCP for evaluation through its internal EPSDT review process to determine medical necessity.

ASD Related ABA Services

Steps for accessing ABA services:

Family must:

1. Obtain an ASD diagnosis as described in, Section 3, Member Eligibility, 3-1 Establishing Medical Necessity;
2. On an annual basis, obtain a written prescription for ABA services from the physician or psychologist;          
3. Obtain a copy of the evaluation tool used to render the diagnosis; and
4. Select an ABA provider
   1. Review the list of Medicaid enrolled ABA providers at http://health.utah.gov/ltc/asd or may contact Medicaid at 1-800-662-9651 to request an enrolled provider list to be mailed or faxed 
   2. Contact the chosen ABA provider and confirm they are willing/able to accept the member onto their caseload.
5. If the member is currently enrolled in the Medicaid Autism Waiver, the diagnostic information provided to establish waiver eligibility will be accepted and the member will not be required to provide additional diagnostic information. 

ABA provider must submit a prior authorization request for initial behavioral assessment and treatment plan development. See Section 7, Prior Authorization of ABA Services.

ABA Procedure Codes

The CPT codes listed below are new Type III codes and are billable only by psychologists or behavior analysts.

Procedure Codes for Behavioral and Functional Assessments

Reimbursement is available for both behavioral and functional assessments. All individuals seeking ABA services will require a behavioral assessment and treatment plan development. In addition to the behavioral assessment, a functional assessment may be medically necessary in some cases. When requesting authorization to conduct a functional assessment, the provider will be required to provide additional information to demonstrate medical necessity.

 

Procedure Codes for Individual Treatment

One-on-one ABA therapy is billed using the procedure codes described in the table below. These codes must be prior authorized prior to performing services. In addition to periodic treatment plan modifications, procedure code 97155 may be used to bill for the psychologist’s or behavior analyst’s case supervision as well as time spent in attending a member’s Individual Education Plan meeting. For members living outside the Wasatch Front, supervision may be conducted via remote access technology.

In the Maximum Allowed column, some service limits are expressed in number of hours per week. This is a description of average utilization over the prior authorization period. Medicaid recognizes that fluctuations in service utilization may vary from week to week. While it is permissible for the provider to exceed the amount listed in the Maximum Allowed column in a particular week and to utilize fewer services in other weeks, it is the provider’s responsibility to track utilization carefully to ensure that utilization does not exceed the total number of units approved over the prior authorization period.

 

 

Procedure Codes for Group Treatment

In addition to individual treatment, group treatment services are available. Services provided in a group setting must be billed with the corresponding modifier to indicate group size. Rates for group services are based on the size of the group. Group services claims submitted without a modifier will be denied. The group-size modifiers are defined below:

• UN – 2 individuals
• UP –  3 individuals
• UQ – 4 individuals
• UR – 5 individuals
• US – 6 or more individuals

 

 

Service Delivery Specifications

Initial ABA Assessment and Treatment Plan Development

The provider must obtain prior authorization to conduct the ABA assessment. See Section 7, Prior Authorization of ABA Services.

The ABA assessment must be conducted by a psychologist or behavioral analyst and must include the following:

1. Date of assessment(s);
2. Name and signature of psychologist or behavior analyst conducting the assessment;
3. Name of standardized assessment(s) used;
4. Use of objective, validated behavioral assessment instruments that includes an assessment of problem behaviors:  (Examples include but are not limited to the Verbal Behavioral Milestone Assessment and Placement Program (VB-MAPP) or Assessment of Basic Language and Learning Skills, Revised (ABLLS-R));
5. Measurement and recording of behavior and baseline performance;
6. Data from parent/caregiver interview;
7. Development of a ABA treatment plan that includes;
   1. Description of target-behaviors
   2. Measurable treatment goals
   3. Method and frequency of assessing objective and measurable treatment protocols
   4. Identification of aggressive or inappropriate behaviors and specific goals intended to decrease the behavior and teach the individual appropriate replacement behavior
8. Clinical certification that ABA is a medically necessary and appropriate treatment to address the treatment goals of the individual; and 
9. Clinical recommendation of the amount of weekly services, delineated by service code, to include:
   1. A description of the setting(s) in which services will be provided
   2. The estimated number of hours of services by setting
   3. Outside the Wasatch Front, if any supervision will be provided via remote access technology, the number of monthly hours provided via this technology must be indicated

ABA Reassessments and Treatment Plan Updates

The ABA reassessments and treatment plan updates must be conducted by a psychologist or behavior analyst. ABA reassessments must occur every 26 weeks. Treatment plan updates must occur at a minimum of every 26 weeks or more frequently if medically necessary.

Reassessments and Treatment Plan Updates must include:

1. Date of reassessment or treatment plan update;
2. Name and signature of the psychologist or behavior analyst conducting the assessment;
3. Name of standardized assessment used;
4. Evaluation of progress toward each behavior treatment goal using an objective, validated assessment instruments that includes an assessment of problem behaviors; Data should be represented in numerical or graphical form and progress must be measured using the same method (graphical or numerical) throughout the individual’s episode of care; 
5. A description of treatment plan revisions that include:
   1. Description of target-behaviors, including aggressive or inappropriate behaviors
   2. Measurable treatment goals
   3. Method and frequency of assessing objective and measurable treatment protocols
6. Clinical certification that ABA continues to be a medically necessary and appropriate treatment to address the treatment goals of individual; 
7. Clinical recommendation of the amount of weekly services, delineated by service code, to include:
   1. A description of the setting(s) in which services will be provided
   2. The estimated number of hours of services by setting
   3. Outside the Wasatch Front, if any supervision will be provided via remote access technology, the number of monthly hours provided via this technology must be indicated 
8. Projected duration of ABA treatment; and
9. A discharge plan, if treatment is expected to conclude within six months of the date of reassessment.

ABA Treatment by BCaBA or Registered Behavior Technician

All ABA treatment must be delivered under a treatment plan developed by and under the supervision of the psychologist or behavior analyst. All ABA procedure codes are billable only by the psychologist or behavior analyst. Assistant behavior analysts, behavior analysts in training and technicians cannot bill Medicaid directly.

Most ABA treatment programs involve a tiered service delivery model in which the psychologist or behavior analyst designs and supervises a treatment program delivered by BCaBA or technician.

In a tiered service delivery model, the BCaBA or technician is responsible for delivering the behavior treatment according to the protocol developed by the psychologist or behavior analyst.

This service may be delivered on a one-on-one basis or in small groups of eight individuals or less.

Psychologist or Behavior Analyst Supervision Requirements of Assistant Behavior Analyst or Registered Behavior Technician

When a tiered service delivery model is utilized the following supervisory activities are required:

1. The psychologist or behavior analyst is responsible for all aspects of clinical direction, supervision, and case management, including activities of the support staff, for example, a BCaBA or technician;
2. The psychologist or behavior analyst must have knowledge of each member of the treatment team’s ability to effectively carry out clinical activities before assigning them; and
3. The psychologist or behavior analyst must be familiar with the individual’s needs and treatment plan and regularly observe the technician implementing the plan, regardless of whether or not there is clinical support provided by a BCaBA or BCBA in training.  The observation must assure the quality of implementation[2] quality of implementation[2]Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers, Second Edition 

The psychologist or behavior analyst is required to provide (direct and indirect) supervision of each member’s case that amounts to a minimum of 10 percent of the time the individual is receiving direct services from a technician. For example: If the technician works with an individual 40 hours per month, the psychologist or behavior analyst is required to spend 4 hours supervising the individual’s case to meet the minimum requirement of 10 percent. The psychologist or behavior analyst must provide direct supervision that involves observing the technician with the individual an average of 50 percent or more of the monthly supervision required on a case. Indirect supervision should comprise the remaining 50 percent of the supervision hours.

In certain situations, depending on the complexity of the client’s ASD symptoms, an additional 10 percent allowance of direct supervision may be authorized with additional approval. If additional direct supervision time is requested, the provider must include documentation to support why the additional hours are medically necessary. Additional time authorized shall not be used for indirect supervision duties.

In areas outside the Wasatch Front, the psychologist or behavior analyst may provide supervision to the assistant behavior analyst or technician via remote access technology. Providing supervision via remote access technology involves using HIPAA compliant technological methods of providing auditory and visual connection between the psychologist or behavior analyst and the assistant behavior analyst or technician who is providing services in a member’s home when the residence is outside of the Wasatch Front. The psychologist or behavior analyst is responsible for assuring the HIPAA compliance of the remote access technology. When billing for supervisory services delivered via remote access technology, the psychologist or behavior analyst must include the “GT” modifier on the claim. Remote access technology cannot be used to complete assessments or reassessments. Assessments and reassessments must be completed in person.

Restrictive Interventions

Although many persons with severe behavioral problems can be effectively treated without the use of any restrictive interventions, restrictive interventions may be necessary on some rare occasions with meticulous clinical oversight and controls. Use of restrictive interventions must be clearly described in the individual’s treatment plan. To ensure medical necessity and that methods of meticulous clinical oversight and controls are clearly described[3]meticulous clinical oversight and controls are clearly described[3] Cited from The Association for Behavior Analysis International Position Statement on Restraint and Seclusion  , treatment plans that include use of restrictive interventions may be subject to additional review by the Medicaid agency.

Multiple Provider Coordination

Members can access multiple providers concurrently, particularly for the purpose of receiving services in multiple settings. For example, one provider may specialize in center-based services and another provider in in-home services.

In all cases, providers may not subcontract with another provider and may not bill on another provider’s behalf.

Service Delivery Settings

To promote generalization and maintenance of therapeutic benefits, ABA services may be delivered in multiple settings. ABA Services may be delivered in multiple settings on the same day.

School-Based Settings

ASD related services identified on the child’s individualized education plan (IEP), as required under the federal Individuals with Disabilities Education Act (IDEA) may be provided in school-based settings.

ASD related services that are listed on an IEP must be provided through the Medicaid School-Based Skills Development Services benefit. Please refer to the School-Based Skills Development Services Provider Manual for information on this benefit.

With exception of the psychologist or behavior analyst’s participation in the child’s annual IEP development meeting, the Medicaid agency shall not reimburse fee-for-service ABA services in school-based settings that are in addition to services listed on an IEP. If the psychologist or behavior analyst, in coordination with the child’s family and school professionals, believe it is medically necessary for the psychologist or behavior analyst to participate in the child’s IEP development meeting, the provider may bill for this specific service on a fee-for-service basis.

Home, Community, Clinic or Center-Based Settings

ABA services can be delivered in a variety of relevant naturally occurring settings in the home and community including targeted settings. Services can also be delivered in clinic or center-based settings.

Non-Covered Services and Limitations

Non-Covered Services

The following services do not meet medical necessity criteria and are non-covered services:

1. ABA services rendered when measurable functional improvement is not expected or progress has plateaued;
2. Services that are investigational, this includes treatments for which the efficacy has not been firmly established by significant empirical study;
3. Services that are primarily educational in nature;
4. Services that are vocationally or recreationally-based;
5. Custodial care services; for purposes of these provisions, custodial care is defined as:
   1. Care that is provided primarily to assist in the activities of daily living, such as bathing, dressing, eating, and maintaining personal hygiene and safety;
6. Services that are provided primarily for maintaining the member’s or anyone else’s safety;
7. Services that are intended to provide supervision of the member
8. Respite care services; for purposes of these provision, respite care is defined as:
   1. Care that is provided primarily to give relief to, or during the absence of, the normal care giver;
9. Services, supplies, or procedures performed in a non-conventional setting including, but not limited to:
   1. Resorts;
   2. Spas;
   3. Therapeutic programs; and
   4. Camps
10. Time spent by the BCaBA or technician charting or collecting data that is occurring separate from the time spent documenting direct observations that occur when the provider is working directly with the member. 
11. Provider’s time traveling to get to the individual’s home or other community setting; and
12. Transportation of the individual. 

Limitations

Service limitations are listed in the “Maximum Allowable” column in the Table in Section 4, Program Coverage, ABA Procedure Codes. If a service request exceeds the maximum allowable, the provider will be required to provide additional documentation to support the need for additional services and the case will be taken to secondary medical review by a single clinician or through the CHEC committee.

Billing

Refer to the provider manual, Section I: General Information, for detailed billing instructions.

Requirements for billing third parties are described in Section I: General Information, 11-5 Billing Third Parties. The one exception to the Section I: General Information, 11-5 Billing Third Parties policy is that the provider will be required to submit documentation regarding other ABA coverage with the initial prior authorization request and with every 26-week recertification request thereafter, rather than with each claim submission. When other insurance coverage is available for ABA services, those services must be exhausted prior to claims being submitted to Medicaid. When the member has additional health insurance that does not cover ABA therapy, or in which there is coverage but it has been exhausted, supporting documentation must be submitted with the prior authorization request (examples of documentation: explanation of benefit or other policy coverage document showing that ABA is not a covered service).

Medicaid as Payment in Full, Client Billing Prohibited

A provider who accepts a member as a Medicaid patient must accept the Medicaid or state payment as reimbursement in full. If a member has both Medicaid and coverage with a responsible third party, do not collect a co-payment that is usually due at the time of service. The provider may not bill the member for services covered by Medicaid. The payment received from Medicaid is intended to include any deductible, co-insurance, or co-payment owed by the Medicaid member. In addition, the administrative cost of completing and submitting Medicaid claim forms are considered part of the services provided and cannot be charged to Medicaid members.

Exceptions to Prohibition on Billing Members

There are certain circumstances in which a provider may bill a Medicaid member. These circumstances can be found in Section I: General Information of the Utah Medicaid Provider Manual, 3-5 Exceptions to Prohibition on Billing Members

Reimbursement Rates

The following rates represent maximum allowable rates. Reimbursement may be up to the amount shown here unless a lower amount is billed.

Prior Authorization of ABA Services

Prior authorization is required for ABA services. Failure to obtain prior authorization will result in denial of Medicaid payment.

General prior authorization (PA) information is provided in the provider manual, Section I: General Information. Code specific coverage and prior authorization requirements are provided on the Medicaid website, Coverage and Reimbursement Lookup Tool at: https://medicaid.utah.gov.

Initial Prior Authorization Request for Behavioral Assessment and Treatment Plan Development

Initial ABA prior authorization requests must be submitted to the Medicaid agency and must include the following:

1. Completed ABA Services Prior Authorization Request Form;
   1. Submission should only include a request for one unit of CPT Code 0359T, Behavior Identification Assessment. (This code is inclusive of time spent to develop the treatment plan). 
   2. If the provider concludes that a functional assessment is needed in addition to the behavioral assessment the provider must include a request for one unit of CPT Code 0360T and must include documentation to support why the additional of a functional assessment is medically necessary.
2. Copy of a written ASD diagnosis by a clinician who is authorized under the scope of their licensure to render a diagnosis using an assessment instrument specified in Section 3, Member Eligibility,3-1 Establishing Medical Necessity;
   1. Copy of the completed clinical assessment tool used to render the diagnosis
   2. ASD Diagnostic Confirmation Form, if applicable
3. Initial written prescription for ABA services, written prescription must be submitted with the prior authorization request annually thereafter;   
4. Documentation regarding other ABA insurance coverage, for members with other insurance (see section 6- Billing)
5. To determine requirements for those transitioning from ABA services in the Medicaid Autism Waiver to services for EPSDT eligible individuals, see 7-4, Initial Prior Authorization Request for Medicaid Autism Waiver Participants.

Prior Authorization Request for Initial Treatment Plan Implementation

1. Completed ABA Services Prior Authorization Request Form;
2. Copy of the treatment plan that includes;
   1. Date
   2. Name and signature of psychologist or behavior analyst who conducted the assessment and developed the treatment plan
   3. Name of standardized assessment used
   4. Description of target-behaviors
   5. Measurable treatment goals
   6. Method and frequency of assessing objective and measurable treatment protocols
   7. Identification of aggressive or inappropriate behaviors and specific goals intended to decrease the behavior and teach the individual appropriate replacement behavior
3. Clinical certification that ABA is medically necessary and appropriate treatment to address the treatment goals of the individual; and
4. Clinical recommendation of the amount of weekly services, delineated by service code, to include:
   1. A description of the setting(s) in which services will be provided
   2. The estimated number of hours of services by setting
   3. Outside the Wasatch Front, description of whether any supervision will be provided via remote access technology.  The number of monthly hours provided via this technology must be indicated.
5. To determine requirements for those transitioning from ABA services in the Medicaid Autism Waiver to services for EPSDT eligible individuals, see 7-4, Initial Prior Authorization Request for Medicaid Autism Waiver Participants.

Prior Authorization Request for Revision of Treatment Plan or 26 Week Recertification

1. Completed ABA Services Prior Authorization Request Form;
2. Copy of Treatment Plan that includes;
   1. Date
   2. Name and signature of psychologist or behavior analyst conducting the assessment
   3. Name of standardized assessment used
   4. Evaluation of progress toward each behavior treatment goal using an objective assessment instrument that includes an assessment of problem behaviors; Data should be represented in numerical or graphical form and progress must be measured using the same method (graphical or numerical) throughout the individual’s episode of care; 
   5. Description of target-behaviors, including aggressive or inappropriate behaviors
   6. Measurable treatment goals
   7. Method and frequency of assessing objective and measurable treatment protocols
3. If there is inadequate process toward meeting target goals to address symptoms and behaviors, or there is no demonstrable progress in a six month period, or specific goals have not been achieved within the estimated timeframes:
   1. The psychologist or behavior analyst must assess the reasons for lack of progress.  Treatment interventions should be modified in an attempt to achieve adequate progress. Requests in which insufficient progress is identified will be submitted for secondary medical review.  
4. Clinical certification that ABA continues to be a medically necessary and appropriate treatment to address the treatment goals of the individual;
5. Clinical recommendation of the amount of weekly services, delineated by service code, to include:
   1. A description of the setting(s) in which services will be provided
   2. The estimated number of hours of services by setting
   3. Outside the Wasatch Front, description of whether any supervision will be provided via remote access technology.  The number of monthly hours provided via this technology must be indicated
6. Documentation regarding other ABA insurance coverage, for members with other insurance (see section 6- Billing);
7. Projected duration of ABA treatment;
8. A discharge plan, if treatment is expected to conclude within six months of the date of the prior authorization request; and
9. The requirements in this section apply to revision or recertification prior authorization requests for previous or current Medicaid Autism Waiver participants as well as non-waiver participants. 

Initial Prior Authorization Request for Medicaid Autism Waiver Participants

Because participants currently enrolled in the Medicaid Autism Waiver have previously established diagnostic and program eligibility, the provider will not be required to submit the diagnosis and ABA services prescription for the initial prior authorization requests. The following information must be included in the initial PA request for these individuals

1. Completed ABA Services Prior Authorization Request Form and
2. Copy of the currently approved Medicaid Autism Waiver care plan.

Updated March 2019

 

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