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The AmeriHealth policy on the evaluation and management of autism spectrum
disorders (ASD) is being updated to communicate our continuing position of
medically necessary criteria for outpatient applied behavioral analysis (ABA)
services for ASD for members enrolled in AmeriHealth commercial products. In
addition, other related structural behavioral services for ASD are covered for
commercial members in AmeriHealth New Jersey.
As a reminder, providers must obtain prior authorization for members in
Pennsylvania when providing evaluation and management services for ASD to
ensure consistent benefit adjudication, as well as appropriate utilization in
accordance with state mandate requirements. Beginning January 2, 2017,
this requirement will also apply when providing these services to members in
New Jersey.
About ABA and/or other related structural
behavioral services
Methodologies to promote learning are believed to enhance verbal and
non-verbal communication, improve developmentally appropriate self-care, teach
social skills, and reduce maladaptive behaviors (e.g., harm to self or others).
These methodologies are based on several model programs, including behavioral,
structured teaching, and/or developmental programs.
Of the many treatment modalities available for the management of ASD, ABA is
arguably the most studied. The ABA modality applies human behavior principles
in various settings (i.e., clinics, schools, homes, and communities) to
diminish substantial deficits in a recipient's adaptive functioning or
significant behavior problems due to ASD. ABA is the process of applying
interventions that are based on the principles of learning derived from
experimental psychology research to systematically change behavior (e.g.,
positive reinforcement). It can also be used to teach new skills and to
demonstrate that the interventions used are responsible for the observable
improvements in behavior. The goal of ABA methods is to replace maladaptive,
interfering behaviors with more desirable, adaptive behaviors and to narrow the
conditions under which maladaptive, interfering behaviors occur.
As set forth in the medical policy for evaluation and management of ASD,
coverage of ABA and/or other related structured behavioral services is
contingent on the following:
- A current (within 24 months), documented diagnosis of ASD consistent with
the DSM-5 criteria, using validated assessment tools, has been made by a
qualified licensed treating professional provider including a physician,
physician assistant, psychologist, or certified registered nurse practitioner
as is consistent with state licensing requirements.
- The qualified licensed treating professional provider is other than the
behavior analyst practitioner performing services related to ABA and/or
other related structured behavioral services.
- An individualized, documented treatment plan has been developed by a
licensed professional provider (e.g., MD/DO, licensed psychologist).
- ABA and/or other related structured behavioral services must be
provided by or under the supervision of the following professionals: a Board
Certified Behavior Analyst-Doctoral (BCBA-D) or Board Certified Behavior
Analyst (BCBA)-graduate-level certification in behavior analysis.
For more information and a complete list of medically necessary criteria for
ABA and/or other related structural behavioral services, review Medical
Policy #07.03.07o: Evaluation and Management of Autism Spectrum Disorders
(ASD), which is currently posted as a Notification and will become effective on
August 19, 2016.
To view the Notification for this policy, visit our Medical Policy
Portal. Select Accept and Go to Medical Policy Online, then select
Commercial under Active Notifications.
If you have any questions, please contact your Provider Partnership
Associate or Network Coordinator.
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