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Independence's 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 Independence commercial products.
As a reminder, providers must obtain prior authorization for evaluation and
management services for ASD to ensure consistent benefit adjudication, as well
as appropriate utilization in accordance with state mandate requirements.
About ABA 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 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 services.
- An individualized, documented treatment plan has been developed by a
licensed professional provider (e.g., MD/DO, licensed psychologist).
- ABA 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 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 Network Coordinator.
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